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Organisatie van geestelijke

gezondheidszorg voor mensen met een

ernstige en persisterende mentale

aandoening. Wat is de

wetenschappelijke basis?

KCE reports 144A

Federaal Kenniscentrum voor de Gezondheidszorg

Centre fédéral d’expertise des soins de santé

2010


Het Federaal Kenniscentrum voor de Gezondheidszorg

Voorstelling: Het Federaal Kenniscentrum voor de Gezondheidszorg is een

parastatale, opgericht door de programma-wet van 24 december 2002

(artikelen 262 tot 266) die onder de bevoegdheid valt van de Minister

van Volksgezondheid en Sociale Zaken. Het Centrum is belast met het

realiseren van beleidsondersteunende studies binnen de sector van de

gezondheidszorg en de ziekteverzekering.

Raad van Bestuur

Effectieve leden: Pierre Gillet (Voorzitter), Dirk Cuypers (Ondervoorzitter), Jo De

Cock (Ondervoorzitter), Frank Van Massenhove (Ondervoorzitter),

Yolande Avondtroodt, Jean-Pierre Baeyens, Ri de Ridder, Olivier De

Stexhe, Johan Pauwels, Daniel Devos, Jean-Noël Godin, Floris Goyens,

Jef Maes, Pascal Mertens, Marc Moens, Marco Schetgen, Patrick

Verertbruggen, Michel Foulon, Myriam Hubinon, Michael Callens,

Bernard Lange, Jean-Claude Praet.

Plaatsvervangers: Rita Cuypers, Christiaan De Coster, Benoît Collin, Lambert Stamatakis,

Karel Vermeyen, Katrien Kesteloot, Bart Ooghe, Frederic Lernoux,

Anne Vanderstappen, Paul Palsterman, Geert Messiaen, Anne Remacle,

Roland Lemeye, Annick Poncé, Pierre Smiets, Jan Bertels, Catherine

Lucet, Ludo Meyers, Olivier Thonon, François Perl.

Regeringscommissaris: Yves Roger

Directie

Algemeen Directeur: Raf Mertens

Adjunct Algemeen Directeur: Jean-Pierre Closon

Contact

Federaal Kenniscentrum voor de Gezondheidszorg (KCE)

Administratief Centrum Kruidtuin, Doorbuilding (10e verdieping)

Kruidtuinlaan 55

B-1000 Brussel

Belgium

Tel: +32 [0]2 287 33 88

Fax: +32 [0]2 287 33 85

Email: info@kce.fgov.be

Web: http://www.kce.fgov.be


Organisatie van geestelijke

gezondheidszorg voor mensen

met een ernstige en

persisterende mentale

aandoening. Wat is de

wetenschappelijke basis?

KCE reports 144A

MARIJKE EYSSEN, MARK LEYS, ANJA DESOMER, ARNAUD SENN, CHRISTIAN LÉONARD

Federaal Kenniscentrum voor de Gezondheidszorg

Centre fédéral d’expertise des soins de santé

2010


KCE reports 144A

Titel: Organisatie van geestelijke gezondheidszorg voor mensen met een

ernstige en persisterende mentale aandoening. Wat is de

wetenschappelijke basis?

Auteurs: Marijke Eyssen (KCE), Mark Leys (KCE), Anja Desomer (KCE), Arnaud

Senn (KCE), Christian Léonard (KCE).

Externe experten: Joël Boydens (Landsbond der Christelijke Mutualiteiten), Paul Cosyns

(Universitair Ziekenhuis Antwerpen), Guido Pieters (Universitair

Psychiatrisch Centrum K.U. Leuven Campus Kortenberg), Bart Van Daele

(Algemeen Ziekenhuis Vesalius Tongeren), Kees Van Heeringen

(Universiteit Gent), Walter Vandereyken (Psychiatrische Kliniek Broeders

Alexianen Tienen).

Externe validatoren: Piet Bracke (HeDeRa-Health & Demographic Research, Vakgroep

Sociologie, Universiteit Gent), Viviane Kovess Masfety (Université Paris

Descartes EA 4069, et Ecole des hautes études en santé publique

Département d’Epidémiologie, Paris, France), Daniel Souery (Laboratoire

de Psychologie Médicale Université Libre de Bruxelles, et Psy Pluriel,

Centre Européen de Psychologie Médicale, Bruxelles)

Conflict of interest: Guido Pieters heeft vergoedingen ontvangen van farmaceutische bedrijven

voor lezingen in verband met niet-farmacologische onderwerpen. Kees

Van Heeringen heeft vergoedingen ontvangen van farmaceutische

bedrijven voor wetenschappelijk advies.

Disclaimer : De externe experten werden geraadpleegd over een (preliminaire) versie

van het wetenschappelijke rapport. Nadien werd een (finale) versie aan de

validatoren voorgelegd. De validatie van het rapport volgt uit een

consensus of een meerderheidsstem tussen de validatoren. Dit rapport

werd unaniem goedgekeurd door de Raad van Bestuur. Alleen het KCE is

verantwoordelijk voor de eventuele resterende vergissingen

of onvolledigheden alsook voor de aanbevelingen aan de overheid

Layout: Ine Verhulst

Brussel, 18 november 2010

Studie nr 2007-04

Domein: Health Services Research (HSR)

MeSH: Mental health services ; Organization and administration ; Evidence-based practice , Health

Services Research.

NLM classificatie: WM 30

Taal: Nederlands, Engels

Formaat: Adobe® PDF (A4)

Wettelijk depot: D/2010/10.273/78

Dit document is beschikbaar van op de website van het Federaal Kenniscentrum voor de

gezondheidszorg.

De KCE-rapporten worden gepubliceerd onder de Licentie Creative Commons « by/nc/nd »

(http://kce.fgov.be/index_nl.aspx?SGREF=5261&CREF=15977).

Hoe refereren naar dit document?

Eyssen M, Leys M, Desomer A, Senn A, Léonard C. Organisatie van geestelijke gezondheidszorg voor

mensen met een ernstige en persisterende mentale aandoening. Wat is de wetenschappelijke basis?

Health Services Research (HSR). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE).

2010. KCE Reports 144A. D/2010/10.273/78.


KCE reports 144A Organisatie geestelijke gezondheidszorg i

VOORWOORD

Zou het kunnen dat het beschavingspeil van een land kan afgemeten worden aan de

manier waarop het omgaat met psychisch zieken en mentaal gehandicapten? Sinds de

kritische analyse van Michel Foucault in het midden van de vorige eeuw heeft de

geestelijke gezondheidszorg in de meeste westerse landen een drastisch nieuwe

wending genomen. De impuls hiertoe was niet in de eerste plaats wetenschappelijk,

maar eerder politiek-filosofisch en ethisch. Tegelijk werd er op vlak van

medicamenteuze behandeling veel meer mogelijk. Het resultaat was dat men anders ging

aankijken tegen mentale stoornissen, en de klassieke aanpak van het psychiatrische

ziekenhuis. Het was duidelijk dat men niet op dezelfde manier wilde verdergaan. Maar

veel minder duidelijk hoe dan wel.

Op basis van een aantal grote principes werd in allerlei richtingen druk

geëxperimenteerd. De ambitie van dit rapport is om te peilen naar wat men vandaag uit

deze ervaringen heeft geleerd rond nieuwe organisatievormen voor geestelijke

gezondheidszorg. De studie leunt nauw aan bij het KCE-rapport n°84 van 2008, ivm.

psychiatrisch verblijf in T-bedden, en de KCE-rapporten n° 103 en 123 ivm. met de

tussentijdse evaluaties van de therapeutische projecten in de geestelijke

gezondheidszorg.

Laten we van bij dit voorwoord de illusie wegnemen dat men het ideale recept kent. De

eventuele gunstige impact van organisatorische vernieuwingen werd maar zelden op

betrouwbare wijze aangetoond. Toch vallen er heel wat lessen te trekken uit de

voorbeelden die we kennen uit binnen- en buitenland. De vertaling ervan naar de

complexe institutionele realiteit van dit land is nog een ander hoofdstuk, maar dat zal

met alle betrokken actoren samen moeten worden geschreven.

Intussen hopen we hiermee een aantal nuttige elementen aan te brengen in de discussie,

en wij danken de externe experten en validatoren die hebben bijgedragen tot het tot

stand komen van deze studie.

Jean-Pierre CLOSON Raf MERTENS

Adjunct algemeen directeur Algemeen directeur


ii Organisatie geestelijke gezondheidszorg KCE reports 144A

INTRODUCTIE

Samenvatting

Op beleidsniveau wordt al sedert de jaren ‘90 nagedacht hoe de geestelijke

gezondheidszorg (GGZ) in België beter georganiseerd kan worden. Dit rapport heeft als

doel bij te dragen tot deze reflectie, en belicht algemene zorgorganisatie enerzijds en

aspecten van zorgcoördinatie en –integratie anderzijds. Het spitst zich toe op mensen

met een mentale aandoening die chronische en complexe zorgbehoeften vertonen.

METHODOLOGIE

Dit rapport is gebaseerd op een literatuurstudie (Medline, Embase, PsycInfo, Cochrane

en CRD-database), en een internationaal overzicht over de zorgorganisatie in 6

Europese landen en Australië. Deze landen weren geselecteerd op basis van input van

experten.

DEFINITIE: ERNSTIGE EN PERSISTERENDE

MENTALE AANDOENING

In beleidsdocumenten over GGZ wordt in België het begrip “personen met een

chronische en complexe zorgbehoefte” gehanteerd. In de wetenschappelijke literatuur

wordt de doelgroep gedefinieerd als “personen met ernstige en persisterende mentale

aandoening (EPM)”. Het begrip is in de literatuur echter niet scherp afgelijnd.

Theoretisch stoelen de meeste omschrijvingen op 3 pijlers: diagnose, duur van de

aandoening, en ernst van de functionele beperkingen. Echter, voor geen enkele van deze

pijlers bestaat er een eensluidende definitie.

De diagnostische groepen waar het meest wordt naar verwezen zijn schizofrenie en

bipolaire stoornissen, soms ook recidiverende/majeure depressies of

persoonlijkheidsstoornissen.

Om te verwijzen naar het chronische karakter wordt wat betreft de “duur” een

minimale ondergrens aangetroffen van 6 maanden.

Functionele beperkingen worden veelal niet expliciet omschreven.

Een voorzichtige schatting raamt de jaarlijkse prevalentie van EPM op ongeveer 1% van

de globale bevolking.

De doelgroep voor dit rapport werd beperkt tot volwassenen. Om praktische redenen

werd gerechtelijke psychiatrie uitgesloten, evenals verslavingsproblematiek, tenzij indien

gecombineerd met een andere mentale aandoening (de “dubbele diagnose”).


KCE reports 144A Organisatie geestelijke gezondheidszorg iii

RESULTATEN LITERATUURSTUDIE

ALGEMENE ZORGORGANISATIE IN DE GGZ

Eerst worden de begrippen deïnstitutionalizering en “balanced care” toegelicht, nadien

volgen de literatuurresultaten.

Deïnstitutionalizering

Deinstitutionalisering, ook wel vermaatschappelijking genoemd, is een maatschappelijkethische

keuze die mee aan de basis ligt van de huidige organisatie van de geestelijke

gezondheidszorg (GGZ). De vermaatschappelijking van GGZ houdt in dat er principieel

voor gekozen wordt om mensen met EPM te benaderen als volwaardige burgers en te

re-integreren in de maatschappij. Deze maatschappelijke tendens kwam op gang in de

jaren ’60, en velen die voorheen in instellingen verbleven bleken inderdaad in staat te

zijn om mits de nodige hulp in de gewone maatschappij te leven, met een aanzienlijk

betere levenskwaliteit. In de tijd liep dit parallel aan een sterke verbetering van de

medicamenteuze behandelingsmogelijkheden, wat zeker de deïnstitutionalisering

ondersteund heeft. Momenteel verwijst deïnstitutionalisering naar het proces waarbij

patiënten zoveel als mogelijk buiten een residentiële zorgvorm worden ondersteund

(dus reductie van bedden), waarbij een diversificatie van het zorgaanbod nodig is om het

breder spectrum van zorgbehoeften te dekken en naar een proces waarbij de

verantwoordelijkheid over de zorg gedeeld wordt door verschillende voorzieningen en

personen.

Het “balanced care” model

Het algemene model waarbinnen organisatie van GGZ momenteel dient gesitueerd te

worden, is het “balanced care” model. In dit model wordt er gestreefd naar het

aanbieden van een diversiteit aan voorzieningen, zodat behandeling en zorg mogelijk zijn

via een zorgaanbod kort bij huis (bij voorkeur), maar ook in een ziekenhuis (zo nodig).

Het model sluit aan bij een logica van een getrapte zorgverlening: het streeft prioritair

naar behandeling en zorg in de eerste lijn, maar indien noodzakelijk zal overgeschakeld

worden naar 2 de of 3 de lijnszorg. In de benadering dienen zowel medische behandeling als

vragen naar praktische zorg en bijstand aan bod te komen. Het model stoelt gedeeltelijk

op wetenschappelijke bewijzen, maar is ook pragmatisch gegroeid uit ervaringen met

het deïnstitutionalizeringsproces, met name vanuit de vaststelling dat de afbouw van

ziekenhuisbedden niet tot in het uiterste moet worden doorgetrokken.

Het “balanced care” model stelt geen exact aantal ziekenhuisbedden of plaatsen in

ambulante zorg voorop. Deze verhouding hangt af van het spectrum aan beschikbare

diensten in een bepaald land of een bepaalde regio, en van de plaatselijke sociale en

culturele opvattingen.

Algemene zorgorganisatie: Literatuurresultaten

Dit overzicht spitst zich toe op zorgverlening buiten het psychiatrisch ziekenhuis,

waarvoor verwezen wordt naar KCE-rapport n°84. De graad van bewijskracht van de

gevonden studies is laag of in het beste geval matig. Er zijn hiervoor tal van

methodologische redenen, waaronder als belangrijkste de complexiteit van de

interventies. Daardoor spelen allerlei randvoorwaarden een rol, die vergelijkingen

tussen interventie- en controlegroep bemoeilijken. Een aantal van de hieronder

beschreven begrippen vertonen onderling een zekere overlap.

• Crisisinterventie in de eigen leefomgeving van mensen met een mentale

aandoening door een ambulant “out-reach” team, blijkt even effectief te

zijn als ziekenhuisopname en wordt meer gewaardeerd door de patiënt en

zijn familie. Dit geldt ook voor crisiszorg in een daghospitaal. Evenwel, voor

sommige personen blijft ziekenhuisopname noodzakelijk.


iv Organisatie geestelijke gezondheidszorg KCE reports 144A

• Er is onvoldoende studiemateriaal beschikbaar over wat de meerwaarde is

van behandeling in een daghospitaal wanneer dit niet kadert in een

crisissituatie. Er is ook onvoldoende studiemateriaal over dagcentra voor

personen met EPM.

• Ambulante multidisciplinaire behandeling in een centrum voor

geestelijke gezondheidszorg kan voor mensen met EPM even effectief zijn als

behandeling tijdens hospitalisatie, en het wordt meer gewaardeerd.

• Thuisbehandeling van mentale aandoeningen met regelmatig huisbezoek en

een gecombineerde medische/ sociale aanpak, kan in vergelijking met een

initiële ziekenhuisopname de duur van eventuele latere ziekenhuisopnames

verminderen, maar dit effect was duidelijker in Amerikaanse studies dan in

Europese.

• “Supported employment” voor mensen met EPM die in aanmerking

komen voor arbeidsrevalidatie is effectiever indien ze wordt aangeboden “on

the spot” in normale arbeidsmarktjobs dan door training in een

revalidatiesetting.

• Over het nut van vroegtijdige interventieteams bij dreigende psychose

kan geen uitspraak gedaan worden gezien er momenteel nog te weinig studies

van voldoende kwaliteit beschikbaar zijn.

ZORGINTEGRATIE, ZORGCONTINUÏTEIT, ZORGPROGRAMMA’S

EN ZORGNETWERKEN

Definities en concepten

Zorgintegratie

Er bestaat heel wat onduidelijkheid en zelfs verwarring over het gebruik van begrippen

zoals zorgintegratie, zorgcontinuïteit, zorgprogramma’s en zorgnetwerken Hieronder

worden een aantal kenmerken samengevat die op een pragmatische wijze samenvatten

wat er over deze concepten in de literatuur aangetroffen werd.

Zorgintegratie is een complex begrip, waarbij de volgende aspecten aan bod komen:

• het niveau van zorgorganisatie waarop zich de integratie afspeelt: gaat het over

integratie op niveau van de individuele patiënt (vb. ACT, zie verder) dan wel

over integratie voor een groep van patiënten en dus op niveau van het

zorgsysteem (vb. tussen twee ziekenhuizen of tussen huisartsen en een

ambulante dienst Geestelijke Gezondheidszorg);

• de intensiteit van zorgintegratie, gaande van zeer los samenwerkingsverband

tot een zeer hoge graad van integratie;

• de afspraken en regels rond deze zorgintegratie, gaande van informele

mondelinge afspraken met veel ruimte voor persoonlijke interpretatie, tot

formele procedures en vaste regels.

Zorgintegratie verwijst met andere woorden naar de wijze waarop de verschillende

onderdelen van een zorgsysteem op elkaar worden afgestemd, hetzij op het niveau van

het landelijk of lokaal beleid, hetzij op niveau van de voorzieningen (binnen één sector

of tussen verschillende sectoren), hetzij op niveau van de professionals. Er bestaan

bepaalde subtypes van zorgintegratie met een eigen begripsinhoud, vb. “Shared care”.

Meer informatie kan gevonden worden in de scientific summary.


KCE reports 144A Organisatie geestelijke gezondheidszorg v

Zorgcontinuïteit

De oorspronkelijke definitie (Bachrach, 1981) van zorgcontinuïteit luidde als volgt: “een

systeem biedt zorgcontinuïteit wanneer de patiënt ononderbroken de verschillende

onderdelen kan doorlopen”. Het gaat meer bepaald om:

• continuïteit in samenwerking tussen sectoren: (1) tussen verschillende

zorgverleners, (2) door volledigheid van het aangeboden zorgpakket, (3) door

beperkte afstand tot en toegankelijkheid van de zorgverlening;

• continuïteit in tijd (longitudinal continuity): (1) het onderhouden van contact

met de patiënt, (2) continuïteit van zorgverlener, (3) van dienstverlening

(zorgplan), (4) en bij de overgang tussen verschillende vormen van

zorgverlening (vb. bij ziekenhuisontslag)

• wijze waarop de patiënt de zorg ervaart als vlot en ononderbroken.

Zorgcontinuïteit wordt in talrijke beleidsdocumenten gezien als een belangrijke

randvoorwaarde voor betere zorg voor personen met mentale aandoening.

Zorgprogramma’s en zorgnetwerken

Een zorgprogramma wordt in dit rapport opgevat als een geheel van activiteiten die

aangeboden worden in de klinische zorg voor een bepaalde groep van personen met

een mentale aandoening.

Een zorgnetwerk is een samenwerkingsverband van voorzieningen of professionals uit

dezelfde of verschillende sectoren die samenwerken om een gemeenschappelijke

doelstelling op het niveau van de patiënt en een patiëntengroep te realiseren. Dergelijk

netwerk is gekenmerkt door herkenbaar lidmaatschap en door afspraken of regels over

de wijze waarop de leden van het netwerk opdrachten vervullen, en de wijze waarop

verantwoordelijkheden en beslissingsbevoegdheden tussen de leden verdeeld zijn.

Impact van zorgintegratie, zorgcontinuïteit, zorgprogramma’s en zorgnetwerken:

literatuurresultaten

Zorgintegratie en -coördinatie op niveau van de individuele patiënt:

• “Assertive community treatment” (ACT) verwijst naar een

multidisciplinair team dat de zorg coördineert in de eigen leefomgeving van

de persoon met EPM, en hem opvolgt ook als hij uit follow-up dreigt te

verdwijnen. Dit team neemt zoveel mogelijk zelf de nodige interventies op,

eerder dan te verwijzen naar andere zorgverleners (dit in tegenstelling tot

case-management, hieronder beschreven). Via ACT blijken meer mensen met

EPM in staat te zijn om zelfstandig te wonen en aan het werk te gaan.

• ACT kan ook voor mensen met EPM het aantal ziekenhuisopnames

verminderen, en kan het aantal mensen dat uit het zicht van de zorgverleners

verdwijnt doen verminderen. Deze resultaten komen overwegend uit studies

in de Verenigde Staten, en konden in een aantal Europese studies niet

bevestigd worden. Recente studies wijzen uit dat het aantal

ziekenhuisopnames vooral verminderd wordt als er vooraf een hoge

frequentie van opname bestond.

• “Case management” (CM) houdt in dat een zorgverlener voor een aantal

patiënten de zorgcoördinatie op zich neemt; er bestaan verschillende

varianten waarvan sommige enigszins aanleunen bij ACT. CM kan ervoor

zorgen dat minder mensen met EPM uit follow-up verdwijnen, maar het effect

op klinische, sociale en andere parameters is minder duidelijk.

• Voor mensen met een dubbele diagnose (mentale aandoening en

verslavingsproblematiek), is er tot hiertoe geen wetenschappelijk bewijs dat

een geïntegreerde aanpak van beide aandoeningen betere resultaten oplevert.


vi Organisatie geestelijke gezondheidszorg KCE reports 144A

Zorgintegratie en -coördinatie op niveau van de zorgorganisaties

Enkele belangrijke grootschalige gerandomiseerde studies tonen aan dat, voor de

doelgroep van EPM, zorgintegratie op niveau van zorginstellingen of tussen verschillende

professionals mogelijk is en dat inspanningen voor een betere zorgintegratie kunnen

leiden tot intensere en vlottere samenwerkingscontacten. Echter, deze studies tonen

aan dat er doorgaans slechts weinig impact is op continuïteit op patiëntniveau, of op

klinische symptomatologie of levenskwaliteit van de persoon met EPM. Dakloze mensen

met EPM kunnen wel langer in stabiele huisvesting gehouden worden.

Er zijn maar weinig studies die specifiek de impact van zorgcontinuïteit tussen

verschillende zorginstellingen bestuderen. Een voorbeeld zijn interventies die de

zorgcontinuïteit bij ontslag uit het ziekenhuis trachten te verbeteren. Ook hier is het

niet duidelijk wat het effect is op klinische of sociale symptomatologie of op

levenskwaliteit van de persoon met EPM, maar omwille van methodologische zwaktes is

meer onderzoek noodzakelijk.

Er werden geen literatuurstudies gevonden over zorgprogramma’s voor personen met

EPM. Voor zorgnetwerken waren er enkele studies beschikbaar, maar hieruit konden

geen eensluidende conclusies getrokken worden.

Tenslotte dient erop gewezen te worden dat de aandacht voor zorgorganisatie niet ten

koste mag gaan van aandacht voor de kwaliteit van inhoudelijke aspecten van de

dienstverlening. Er is immers geen overtuigend bewijs dat zorgintegratie en

zorgcontinuïteit tot minder klinische symptomatologie of betere levenskwaliteit van

mensen met EPM leiden. Bovendien: “ineffective services are not improved by better

integration” (Goldman 1994).

INTERNATIONAAL OVERZICHT

In deze studie wordt een algemeen overzicht geschetst van de organisatie van de

geestelijke gezondheidszorg in Frankrijk, Nederland, Spanje, Denemarken, Engeland,

Australië, en België.

In al deze landen zijn hervormingsprocessen in de geestelijke gezondheidszorg aan de

gang, en alle landen ondervinden hierbij tal van moeilijkheden.

Een steeds terugkerend probleem bij het uitvoeren van deze studie was dat er

nauwelijks informatie of cijfermateriaal te vinden was over hoe bepaalde concepten

gerealiseerd werd op het terrein, over de context waarin dit gebeurde, en over de

uiteindelijke impact. Dit maakt het zeer moeilijk om de gevonden informatie te

interpreteren.

... “als alle andere mensen met een medisch of psychosociaal probleem”...

Alle beschreven landen streefden er de afgelopen decennia naar om de behandeling en

ondersteuning van mensen met een mentale aandoening zoveel mogelijk te laten

aansluiten bij de rest van de gezondheids- en welzijnszorg, zodat zij behandeld zouden

worden als alle andere burgers.


KCE reports 144A Organisatie geestelijke gezondheidszorg vii

Deïnstitutionalizering en reïntegratie: waar staan we nu?

Van de bestudeerde landen is Australië zeer ver gevorderd in een organisatiemodel dat

gebaseerd op het deïnstitutionaliseringsprincipe: er is een zeer laag totaal aantal

psychiatrische bedden (voor volwassenen 25/100.000 populatie in 2007, te vergelijken

met 127/100.000 in Belgie), en 53% hiervan is gesitueerd in een algemeen ziekenhuis (in

België is dit 18%). Australische evaluatierapporten wijzen er echter op dat het aanbod

aan aangepaste woongelegenheid buiten het ziekenhuis nog steeds onvoldoende

ontwikkeld is, al zijn er voor zorgvoorziening wel veel inspanningen gebeurd.

Het aantal bedden in psychiatrische ziekenhuizen ligt in meerdere van de andere

bestudeerde landen nog hoog (vb. Frankrijk, Nederland, zie overzichtstabel in Scientific

summary). Er wordt erkend dat aangepaste woongelegenheid en dienstverlening in de

eigen leefomgeving onvoldoende ontwikkeld zijn. In Engeland daarentegen is het

residentiële aanbod relatief laag, en wordt er een zeer sterke nadruk gelegd op

ambulante specialistische zorg via CMHTs (community mental health teams), inclusief

“assertive outreach teams” die zo nodig op verplaatsing werken voor de EPM populatie.

In België zijn er voor verblijfsmogelijkheden buiten het ziekenhuis zoals PVT

(psychiatrische verzorgingstehuizen) en IBW (initiatieven voor beschut wonen) lange

wachtlijsten hoewel de wettelijk vastgelegde maximumnormen niet bereikt zijn.

Aspecten als dagbezigheid of arbeidsgerelateerde ondersteuning worden onvoldoende

gestructureerd aangepakt, wat overigens in de meeste Europese landen het geval is.

In enkele van de bestudeerde landen wordt zeer sterk de nadruk gelegd op de rol van

de huisarts in de diagnose en behandeling van mentale aandoeningen in het algemeen

(niet enkel EPM). Hierin speelt de globale gezondheidszorgorganisatie van deze landen

een rol. In Australië kende het invoeren van speciale huisartstarieven voor geestelijke

gezondheidszorg een groot succes; huisartsen worden ook gestimuleerd om de nodige

vorming te volgen. In 2005 werd 5% van het totale budget voor geestelijke

gezondheidszorg toegekend aan huisartsen. Ook psychiaters hebben bepaalde financiële

voordelen indien ze de samenwerking met een huisarts ondersteunen. In Engeland

wordt de rol van eerstelijnszorg voor mentale aandoeningen sterk benadrukt in officiële

documenten, maar het is niet bekend in hoeverre de huisarts ook daadwerkelijk deze

rol opneemt. In Spanje worden 89% van alle mentale aandoeningen in de eerste lijn

behandeld. In de literatuur rijzen er hierbij soms kritische vragen over kwaliteit, temeer

omdat dit gesitueerd dient te worden binnen een relatief beperkt aanbod van

gespecialiseerde zorg (zie overzichtstabel 14.1.6 in Scientific summary).

Geïntegreerde zorg, zorgcontinuïteit, zorgprogramma’s en zorgnetwerken

In elk van de bestudeerde landen, inclusief België, worden concepten als

zorgcoördinatie, zorgcontinuïteit, en geïntegreerde zorg in talrijke officiële documenten

expliciet en uitvoerig naar voren geschoven. In alle onderzochte landen leidt dit tot een

zoektocht waarbij men experimenteert met de wijze waarop dit best gerealiseerd kan

worden. Echter, nog in geen enkel land bestaat de indruk dat men reeds tot een

definitieve, bevredigende oplossing gekomen is. In de meeste gevallen zijn de concrete

resultaten van de ingevoerde maatregelen niet specifiek bestudeerd.


viii Organisatie geestelijke gezondheidszorg KCE reports 144A

Niveau van de individuele patiënt:

Coördinatie van geestelijke gezondheidszorg & coördinatie tussen

gezondheids- en welzijnszorg

In Frankrijk en Spanje wordt deze rol reeds meerdere decennia officieel toevertrouwd

aan de centra voor geestelijke gezondheidszorg. Deze centra, die gerekend worden tot

de specialistische gezondheidszorg, slagen hier echter niet in, om diverse redenen, o.a.

omwille van wijdverbreide wachtlijsten.

Ook in Engeland nemen de centra voor geestelijke gezondheidszorg (CMHTs) een

coördinerende rol op, en zij lijken deze rol beter waar te maken. Voor de EPM dienen

de CMHTs bovendien assertive outreach teams te organiseren, die eveneens

coördinatie op nemen. Daarnaast maakt men ook sedert de jaren ’90 gebruik van de

“Care Program Approach” (CPA). Dit betekent dat er voor mensen met EPM een

zorgplan opgemaakt wordt, dat regelmatig geëvalueerd wordt, en waarbij ook een

zorgcoördinator aangeduid wordt. Er bestaat echter kritiek dat het CPA systeem

formalistisch zou zijn en dat in realiteit het samenwerken tussen gezondheidszorg en

welzijnszorg moeizaam blijft.

In Australië wordt zorgcoördinatie op medisch vlak toevertrouwd aan de huisarts of

psychiater die als belangrijkste behandelende arts wordt beschouwd; voor mensen met

EPM wordt een zorgcoördinator gefinancierd die gezondheids- en welzijnszorg

coördineert. Resultaten over het al dan niet functioneren van deze zorgcoördinatie zijn

niet bekend.

Nederland introcudeerde met het oog op zorgcontinuïteit op niveau van de

zorggebruiker “zorgprogramma’s” in de geestelijk gezondheidszorg (naar schatting door

60% van de bestaande dienstverleners, vaak lokaal ontwikkelde programma’s). Er

werden geen documenten gevonden die de inhoudelijke kwaliteit of effecten van deze

zorgprogramma’s bestudeerden.

In België werd tot recent via de “Therapeutische projecten” uitgeprobeerd hoe men tot

een betere coördinatie zou kunnen komen (en dit niet enkel op patiëntniveau).

Niveau van de zorgorganisaties of algemeen beleid:

Coördinatie van geestelijke gezondheidszorg

In Frankrijk wordt dit aangemoedigd via netwerkvorming tussen organisaties, tot

hiertoe zonder veel succes.

Engeland heeft voor het ondersteunen van veranderingen ruim 170 “LITs” of “local

implementation teams” in het leven geroepen. Deze teams hebben de specifieke taak

teams die zorg aanbieden binnen een bepaalde regio, op te starten, te superviseren en

te begeleiden. Deze LITs dienen erover te waken dat de zorgnoden in hun regio gedekt

zijn. Hoewel dit niet hun eerste doelstelling is, spelen LITs een globale rol in de

coördinatie tussen residentiële en ambulante zorg. Dit model van LITs wordt meestal

vrij positief geëvalueerd. Er bestaan ook LITs voor andere doelgroepen dan personen

met een mentale aandoening.

In Australië stelt de overheid op regelmatige tijdstippen, en dit reeds sinds de jaren ’90,

een Mental Health Care Plan op, en dit in samenwerking met alle actoren van de

geestelijke gezondheidszorg. Zorgcoördinatie binnen geestelijke gezondheidszorg is

hierbij een constant aandachtspunt.


KCE reports 144A Organisatie geestelijke gezondheidszorg ix

In België valt een groot deel van de zorg en ondersteuning van personen met EPM

onder de federale ziekteverzekering. Daar staat tegenover dat zorg en ondersteuning

van langdurig zorgbehoevenden een bevoegdheid is van de gemeenschappen en

gewesten, met als aanbod diverse woonfuncties, dagopvang, beschutte werkplaatsen,

persoonlijke assistentie-budget, tijdelijke opvang om mantelzorgers te ontlasten etc. In

het geval van mentale aandoeningen (met uitzondering van personen met autisme)

beperkt de regionale bevoegdheid zich voornamelijk tot de organisatie van centra voor

geestelijke gezondheidszorg/ centres de santé mentale. Het huidige zorgaanbod voor

mensen met EPM is dan ook minder gevarieerd dan dat van personen met een mentale

of andere handicap. In het algemeen maakt spreiding van bevoegdheden de organisatie

van zorg vaak onoverzichtelijk en complex. Recent werd er via het interministeriële

programma “een betere GGZ” in het kader van het zogenaamde ‘artikel 107’, een

volgende stap gezet naar meer overleg en samenwerking binnen de geestelijke

gezondheidszorg, deze plannen worden momenteel verder geconcretiseerd.

Tevens werd het pilootproject “psychiatrische zorg in de thuissituatie” dat overleg en

informatiedoorstroming tussen 1ste en 2-3 de lijn stimuleerde, definitief bestendigd.

Verder zijn op Federaal niveau de “Overlegplatforms” georganiseerd, die een basis

vormen voor continu overleg tussen de verschillende actoren ivm. planning van

geestelijke gezondheidszorg. In de Waalse regio dienen de “Centres de référence de santé

mentale” de coördinatie te verzorgen tussen de verschillende Centra voor geestelijke

gezondheidszorg.

Coördinatie tussen gezondheids- en welzijnszorg

In Engeland spelen LITs een globale rol in de coördinatie tussen “cure” en “care”.

Verder hebben NHS Care Trusts als specifieke taak de samenwerking tussen NHS

(health care) en locale autoriteiten (welfare) te faciliteren. Ook bestaat in Engeland de

verplichting om op lokaal niveau te overleggen tussen organisatoren van

gezondheidszorg en welzijnszorg. De concrete resultaten van al deze maatregelen

werden echter niet specifiek bestudeerd.

In Denemarken zijn “health agreements” tussen gezondheids- en welzijnszorg (tussen

regio’s en lokale autoriteiten) verplicht, waarbij obligaat de sociale voorzieningen voor

EPM aan bod dienen te komen. Denemarken kent ook Regionale platformen, waar een

voortdurend overleg ivm. planning van gezondheids- en welzijnszorg plaatsvindt.

In Australië worden bij het opstellen van het Mental Health Care Plan ook actoren uit

het domein van welzijnszorg betrokken. Dit Plan wordt regelmatig grondig geëvalueerd,

inclusief de verschillende deelaspecten van geestelijke gezondheidszorg maar ook

welzijn; de resultaten worden in een gemeenschappelijk rapport (gezondheidszorgwelzijnszorg)

publiek bekend gemaakt.

In Nederland was de organisatie van de geestelijke gezondheidszorg tot 2008 gebaseerd

op geïntegreerde zorgcircuits: zowel behandeling (“care”) als praktische hulp en bijstand

(“cure”) kwamen aan bod. Het geheel werd door één enkele overheidsinstantie (het

AWBZ) gefinancierd, dit speelde volgens officiële documenten een belangrijke rol in het

slagen van het systeem. Het systeem werd in 2008 volledig hervormd in het kader van

de algemene hervormingen in Nederland maar ook omdat de GGZ teveel verkokerde

(“kokerzorg”), en te weinig was afgestemd op de algemene gezondheids- en

welzijnszorg. In deze “kokerzorg” zouden de keuzemogelijkheden voor de

zorggebruikers te beperkt geweest zijn. Tenslotte kregen de grote zorgvoorzieningen te

veel macht en was hun beleid onvoldoende transparant.

In België behoort het tot de doelstellingen van het interministeriële programma “een

betere GGZ” in het kader van ‘artikel 107’, dat ook de samenwerking tussen GGZ en

dienstverlening voor welzijn geoptimaliseerd wordt.


x Organisatie geestelijke gezondheidszorg KCE reports 144A

AANBEVELINGEN

Research agenda

• Uitgaande van het model van “gebalanceerde zorg” en de huidige Belgische

zorgorganisatie, is verdere deïnstitutionalizering van mensen met ernstige

en persisterende mentale aandoeningen aangewezen.

• Dit is enkel mogelijk mits het gelijktijdig uitbouwen van aangepaste zorg- en

opvangvormen kort bij de eigen leefwereld van de patiënt, die een maximale

graad van integratie in de maatschappij mogelijk maken, en die vertrekken

van de individuele noden van elke patiënt.

• De overheid dient te zorgen voor de verdere uitbouw van een mix van

beschermde woonvormen, met diverse mogelijkheden wat betreft

zelfstandigheid en met diverse graden aan ondersteuning.

• Daarnaast dient voor de mensen met EPM niet-residentiële zorg en

ondersteuning planmatig uitgebouwd te worden. Specifieke aandacht is

wenselijk voor begeleiding in dagactiviteiten, en ondersteuning bij hervatting

van werkactiviteiten.

• Intensieve multidisciplinaire begeleiding en zorgcoördinatie voor mensen

met EPM die frequent gerehospitaliseerd worden, dient gestimuleerd te

worden, vb. op basis van het ACT model.

• Financiële aspecten mogen voor de patiënt geen belemmering vormen om

door te stromen naar de meest geschikte zorgvorm.

• Verdere uitbouw dient te vertrekken van de bestaande zorgstructuren, en

gebeurt best op een planmatige, gefaseerde wijze. Op basis van de huidige

wetenschappelijke kennis en beschikbare cijfers is het immers niet mogelijk

om exact te voorspellen welke zorgvormen en hoeveel plaatsen er nodig

zullen zijn.

• Tussentijdse kritische evaluaties zijn noodzakelijk, zowel op niveau van het

zorgproces als op niveau van de patiënt. Australië kan hierbij als voorbeeld

dienen.

• Het is absoluut noodzakelijk om in beleidsdocumenten of discussies over

zorgorganisatie steeds expliciet te omschrijven wat men verstaat onder

zorgcircuits, zorgnetwerken, zorgcoördinatie, geïntegreerde zorg of

continuïteit van zorg, om te vermijden dat eenzelfde term voor zeer diverse

organisatorische begrippen gebruikt wordt.

• De voorgestelde zorguitbouw vereist de nodige coördinatie tussen het

federale, en de communautaire en regionale beleidsniveaus.

• Met de MPG (minimale psychiatrische gegevens) beschikt België over een

naar internationale normen zeer gedetailleerd databestand van de

psychiatrische ziekenhuisopnames, inclusief een aantal functionele gegevens

over deze patiënten. Een systematische, diepgaande wetenschappelijke

analyse en exploitatie van deze gegevens is wenselijk en kan potentieel

belangrijke informatie opleveren voor de overheid.

• Men dient een manier te zoeken om het traject van mensen met EPM ook

na hun ontslag uit het ziekenhuis op te volgen. Dit zou kunnen gebeuren op

basis van een combinatie of een uitbreiding van bestaande registraties.


KCE Reports 144 Evidence Based Mental Health Services 1

Scientific summary

Table of contents

1 INTRODUCTION AND RESEARCH QUESTIONS .................................................... 5

2 GENERAL BACKGROUND: DEFINITIONS AND SCOPE OF THE STUDY ......... 7

2.1 CHRONIC AND COMPLEX MENTAL DISORDERS: DEFINITIONS AND SCOPE OF THE

STUDY ............................................................................................................................................................ 7

2.1.1 Definition: Mental disorder ............................................................................................................ 7

2.1.2 Definition: “Chronic” or “severe and persistent” mental disorders ..................................... 8

2.1.3 Additional limitations of the scope of this study ....................................................................... 8

2.2 ORGANISATIONAL FORMS OF PSYCHIATRIC CARE: DEFINITIONS AND SCOPE OF THE

STUDY ............................................................................................................................................................ 9

2.2.1 Introduction ....................................................................................................................................... 9

2.2.2 Definition: Mental health service .................................................................................................. 9

2.2.3 Typology of mental health services .............................................................................................. 9

2.2.4 Additional limitations of the scope of this study ..................................................................... 12

2.3 OUTCOME EVALUATION: GENERAL PERSPECTIVE ..................................................................... 12

2.4 EVIDENCE-BASED HEALTH SERVICES RESEARCH AND HEALTH CARE POLICY .............. 13

3 LITERATURE REVIEW: METHODOLOGY ............................................................... 18

3.1 INTRODUCTION ...................................................................................................................................... 18

3.1.1 European Service Mapping Schedule (ESMS) ............................................................................ 18

3.1.2 Types of study to be included ..................................................................................................... 18

3.2 SEARCH STRATEGY, IN- AND EXCLUSIONCRITERIA ................................................................. 18

3.2.1 Cochrane Database of Systematic Reviews and CRD Database (CRD-reports, DARE,

HTA) ........................................................................................................................................................... 18

3.2.2 Medline (Ovid), PsycInfo, Embase. .............................................................................................. 19

4 LITERATURE REVIEW: RESULTS ............................................................................. 21

4.1 DEFINITIONS .............................................................................................................................................. 21

4.2 MENTAL HEALTH SERVICES, RESIDENTIAL, NON-HOSPITAL .................................................. 28

4.2.1 Mental Health Services, Residential, Acute, Non-hospital. .................................................... 28

4.2.2 Mental Health Services, Residential, Non-acute, Non-hospital, Indefinite stay (Daily

support, 24h-support, Lower than daily support). ............................................................................... 29

4.2.3 Mental Health Services, Residential, Non-acute, Non-hospital, Time limited stay. ......... 32

4.3 MENTAL HEALTH SERVICES, OUT-PATIENT AND COMMUNITY ........................................... 33

4.3.1 Mental Health Services, Out-patient and community, Emergency care (mobile/ nonmobile).

......................................................................................................................................................... 33

4.3.2 Mental Health Services, Out-patient and community, Continuing care. ............................ 35

4.4 MENTAL HEALTH SERVICES, DAY & STRUCTURED ACTIVITY ................................................ 46

4.4.1 Mental Health Services, Day & structured activity, Acute. ................................................... 47

4.4.2 Mental Health Services, Day & structured activity, Non-acute, Work or work-related

activity (high & low intensity). .................................................................................................................. 49

4.4.3 Mental Health Services, Day & structured activity, Non-acute, Other structured activity,

(high & low intensity). ................................................................................................................................ 51

4.4.4 Mental Health Services, Day & structured activity, Non-acute, Social support, (high &

low intensity). .............................................................................................................................................. 52

4.5 CONTINUITY OF CARE, SERVICES & SYSTEMS INTEGRATION, CARE PROGRAMS ......... 52

4.5.1 Continuity of care .......................................................................................................................... 52

4.5.2 Services and systems integration ................................................................................................ 54

4.5.3 Care programs, Care pathways................................................................................................... 60

5 LITERATURE REVIEW: CONCLUSIONS ................................................................. 61

5.1 DIAGNOSIS OF “CHRONIC AND COMPLEX” OR “SEVERE AND PERSISTENT” MENTAL

ILLNESS. ........................................................................................................................................................ 61

5.1.1 Definition of “severe and persistent” mental disorders ........................................................ 61

5.1.2 Prevalence of severe and persistent mental disorders ........................................................... 62


2 Evidence Based Mental Health Services KCE reports 144

5.2 LITERATURE EVIDENCE ON ORGANIZATION OF MENTAL HEALTH CARE ..................... 63

5.2.1 Methodological reflections ........................................................................................................... 63

5.2.2 Which mental health care services to organize for SMI persons? ....................................... 64

5.2.3 Integrated care, Continuity of care, Care pathways and Networks of care for SMI

persons: the evidence................................................................................................................................. 67

5.3 LIMITATIONS OF THE LITERATURE REVIEW .................................................................................. 70

6 INTRODUCTION INTERNATIONAL OVERVIEW ................................................. 72

6.1 SCOPE OF THIS SECTION ..................................................................................................................... 72

6.2 SELECTION OF THE COUNTRIES ....................................................................................................... 72

6.3 GENERAL METHODOLOGY ................................................................................................................. 73

7 BELGIUM ........................................................................................................................ 74

7.1 LITERATURE SEARCH: METHODOLOGY ......................................................................................... 74

7.2 GENERAL ORGANIZATION OF THE BELGIAN HEALTH CARE SECTOR ............................. 74

7.3 GENERAL FINANCING OF THE BELGIAN HEALTH CARE SECTOR ....................................... 75

7.3.1 General principles .......................................................................................................................... 75

7.3.2 The statutory insurance system .................................................................................................. 75

7.3.3 The complementary insurance system ...................................................................................... 76

7.3.4 The private system ......................................................................................................................... 76

7.4 GENERAL ORGANIZATION AND FINANCING OF SUPPORT SERVICES FOR PEOPLE

WITH DISABILITIES .................................................................................................................................. 76

7.5 ORGANIZATION OF THE MENTAL HEALTH CARE IN BELGIUM ........................................... 76

7.5.1 Historical context .......................................................................................................................... 77

7.5.2 Third reformation wave: care circuits and networks of care ............................................... 78

7.5.3 Data collection, scientific institutes ............................................................................................ 83

7.5.4 Mapping of existing services ......................................................................................................... 83

7.5.5 The ‘Mental health care tree’ in Belgium .................................................................................. 85

7.6 FINANCING OF THE MENTAL HEALTH CARE SECTOR ............................................................ 95

7.6.1 Global data ....................................................................................................................................... 95

7.6.2 Approach per sector of activities ............................................................................................... 95

7.7 SPECIFIC PROBLEMS OF THE BELGIAN MENTAL HEALTH ORGANIZATION .................... 96

8 FRANCE .......................................................................................................................... 98

8.1 LITERATURE SEARCH: METHODOLOGY ......................................................................................... 98

8.2 ORGANIZATION AND FINANCING OF THE HEALTH CARE SECTOR: SOME ASPECTS 98

8.2.1 The statutory insurance system .................................................................................................. 98

8.2.2 The complementary insurance system ...................................................................................... 99

8.2.3 The financing of the hospital sector ........................................................................................... 99

8.2.4 The French health care system: which problems?................................................................. 100

8.2.5 Impact of quality assessment in the French health care system. ........................................ 100

8.3 THE MEDICAL SOCIAL SECTOR IN FRANCE ................................................................................ 101

8.4 ORGANIZATION OF THE MENTAL HEALTH CARE SECTOR IN FRANCE ......................... 102

8.4.1 Historical background ................................................................................................................. 102

8.4.2 General principles – the sectorization ..................................................................................... 103

8.4.3 Evolution of the French policy from 2003 onwards ............................................................. 105

8.4.4 Mapping of existing services: Introduction .............................................................................. 108

8.4.5 The ‘Mental health care tree’ in France ................................................................................... 111

8.5 FINANCING OF THE MENTAL HEALTH CARE SECTOR .......................................................... 119

8.5.1 Global data ..................................................................................................................................... 119

8.5.2 Data per sector of activities ....................................................................................................... 119

8.5.3 Key issues on financing of psychiatric care ............................................................................. 121

8.6 THE FRENCH MENTAL HEALTH CARE ORGANIZATION: DISCUSSION ........................... 122

9 THE NETHERLANDS ................................................................................................. 123

9.1 LITERATURE SEARCH: METHODOLOGY ....................................................................................... 123

9.2 GENERAL HEALTH CARE ORGANISATION .................................................................................. 123

9.2.1 History ............................................................................................................................................ 123


KCE Reports 144 Evidence Based Mental Health Services 3

9.2.2 Recent changes ............................................................................................................................. 123

9.3 GENERAL FINANCING OF HEALTH CARE .................................................................................... 125

9.4 MENTAL HEALTH CARE ORGANISATION .................................................................................... 126

9.4.1 History ............................................................................................................................................ 126

9.4.2 Specific programmes: care programs and care circuits ........................................................ 126

9.4.3 Most recent changes .................................................................................................................... 127

9.4.4 Scientific institutes, Knowledge centers for mental disorders ........................................... 128

9.4.5 Mapping of existing services ....................................................................................................... 128

9.5 FINANCING OF MENTAL HEALTH CARE ...................................................................................... 133

9.5.1 Global data ..................................................................................................................................... 133

9.5.2 Data per sector of activities ....................................................................................................... 133

9.6 ADVANTAGES/DISADVANTAGES OF THE DUTCH MENTAL HEALTH CARE

ORGANIZATION .................................................................................................................................... 135

10 SPAIN ............................................................................................................................ 137

10.1 LITERATURE SEARCH: METHODOLOGY ....................................................................................... 137

10.2 ORGANIZATION AND FINANCING OF THE HEALTH CARE SECTOR .............................. 137

10.2.1 Organizational overview of the health care system .............................................................. 137

10.2.2 Financing of the health care sector........................................................................................... 138

10.3 ORGANIZATION OF THE MENTAL HEALTH CARE IN SPAIN ............................................... 139

10.3.1 The ‘psychiatric reform’ .............................................................................................................. 139

10.3.2 General principles ........................................................................................................................ 140

10.3.3 Mental health indicators: heterogeneity between Autonomous Communities .............. 142

10.3.4 Social services for people with disability or dependence .................................................... 142

10.3.5 Mapping of existing services ....................................................................................................... 143

10.3.6 The ‘Mental health care tree’ in Spain ..................................................................................... 144

10.4 FINANCING OF THE MENTAL HEALTH CARE SECTOR .......................................................... 147

10.4.1 Global data ..................................................................................................................................... 147

10.4.2 Approach per sector of activities ............................................................................................. 147

11 DENMARK .................................................................................................................... 150

11.1 LITERATURE SEARCH: METHODOLOGY ....................................................................................... 150

11.2 GENERAL ORGANISATION OF HEALTH CARE ........................................................................... 150

11.2.1 Recent important health care policy changes ......................................................................... 150

11.2.2 The policy-levels in health care ................................................................................................. 151

11.2.3 Organisation of the Danish health care sector ...................................................................... 152

11.2.4 Funding in general terms ............................................................................................................. 153

11.3 MENTAL HEALTH SERVICES ORGANISATION ............................................................................. 153

11.3.1 Mental health care reforms ........................................................................................................ 153

11.3.2 Mental health care organisation: the ‘Mental health care tree’ in Denmark ................... 155

11.4 FINANCING OF THE HEALTH CARE SECTOR ............................................................................. 157

11.4.1 Global data ..................................................................................................................................... 157

11.4.2 Approach per sector of activities ............................................................................................. 158

11.4.3 Financing of the mental health care sector ............................................................................. 158

12 ENGLAND .................................................................................................................... 159

12.1 LITERATURE SEARCH: METHODOLOGY ....................................................................................... 159

12.2 GENERAL ORGANISATION OF HEALTH CARE IN ENGLAND .............................................. 159

12.3 GENERAL FINANCING PRINCIPLES OF HEALTH CARE ............................................................ 160

12.4 ORGANISATION OF MENTAL HEALTH CARE: ............................................................................ 161

12.4.1 Policy reforms in the organisation of mental health care .................................................... 161

12.4.2 National institute for mental health ......................................................................................... 163

12.4.3 A review of community mental health services ..................................................................... 163

12.5 DESCRIPTIVE CHARACTERISTICS OF MENTAL HEALTH SERVICES ...................................... 165

12.5.1 Preliminary comments ................................................................................................................. 165

12.5.2 Mental health care trusts and primary care trusts ................................................................ 166

12.5.3 Residential mental health services ............................................................................................ 167


4 Evidence Based Mental Health Services KCE reports 144

12.6 FUNDING OF MENTAL HEALTH CARE .......................................................................................... 172

13 AUSTRALIA ................................................................................................................. 173

13.1 LITERATURE SEARCH: METHODOLOGY ....................................................................................... 173

13.2 ORGANISATION AND FINANCING OF THE HEALTH CARE SECTOR ............................... 173

13.2.1 Organisation of the Australian health care system ............................................................... 173

13.2.2 Financing principles of health care ............................................................................................ 173

13.2.3 Support services for people with disabilities .......................................................................... 174

13.3 ORGANISATION OF THE MENTAL HEALTH CARE IN AUSTRALIA ..................................... 175

13.3.1 General organisation of the mental health care .................................................................... 175

13.3.2 Recent reforms ............................................................................................................................. 175

13.3.3 Mapping of the existing services: introduction ....................................................................... 181

13.3.4 The mental health tree in Australia .......................................................................................... 182

13.4 FINANCING OF THE MENTAL HEALTH CARE SECTOR .......................................................... 187

13.5 DISCUSSION AND CONCLUSION ................................................................................................... 188

13.5.1 The National Mental Health Strategy and its evaluation ...................................................... 188

13.5.2 Results of the reform process ................................................................................................... 190

14 INTERNATIONAL OVERVIEW: CONCLUSIONS ................................................ 192

14.1.1 Deinstitutionalization: where are we now? ............................................................................ 192

14.1.2 The balanced care model ............................................................................................................ 193

14.1.3 Organization of contemporary mental health care. .............................................................. 194

14.1.4 Care organization: integrated care, continuity of care, care programs and networks of

care ......................................................................................................................................................... 195

14.1.5 Evaluation of quality of care, Performance indicators .......................................................... 198

14.1.6 International overview ................................................................................................................ 199

14.2 OVERALL CONCLUSION KEY POINTS ........................................................................................... 209

15 REFERENCES ............................................................................................................... 211


KCE Reports 144 Evidence Based Mental Health Services 5

1 INTRODUCTION AND RESEARCH

QUESTIONS

In 1999, the Minister of Public Health Care, decided to fund new initiatives in Mental

Health Care. As an answer to the international tendency towards de-institutionalisation

of psychiatric care, these new initiatives should deal with collaboration between

different care providers in mental health care. The Belgian Government also approved

the WHO Resolution of 2002, based on the World Health Report 2001, in which it is

advised to adjust the global health care organisation of the country to the specific

situation of mental health care.

The National Advisory Council for Hospital Services further elaborated these decisions,

and on July 10 th 2002, they formulated an advice with the following key-concepts: 1. all

mental health care should be centralized around and tailored to the needs of each

individual patient. 2. quality of care implies continuity of care, in an environment that is

as natural as possible to the patient. 3. to realize these aims, mental health care

providers should collaborate starting from the competences of each of them. It was

proposed to explore this renewed vision on mental health care by initiating “projects”,

which would be evaluated and eventually re-oriented before they would be

implemented nationally. In 2004, the responsible Ministers decided to give priority to

the group of “chronic, complex and long-lasting” mental disorders; and a royal decree

on October 22 2006 stipulated the conditions for the creation and development of the

projects.

The National Institute for Health and Disability (NIHDI) and the Federal Public Services

(FPS) for Public Health were mandated to elaborate the projects. (also called

“Therapeutic Projects”). Their evaluation is dealt with separately (1 st document: KCEreport

n° 103)

At the same time, it was felt that it would be appropriate to evaluate the current

scientific knowledge and literature evidence on organisational aspects in mental health

care, and to evaluate the evolutions in psychiatric care in other Western countries.

These topics are the main objectives of this KCE-report.

The research questions of this report are formulated as follows:

First question

How can chronic complex psychiatric patients be defined? Which diagnostic groups or

subcategories are generally distinguished under this umbrella term? Which scientific

criteria can be used to identify the group?

Second question

Which evidence and knowledge is available on the outcomes of organisational health

services aiming at rehabilitation and integration of the target groups? How do these

organisational models fit into the concept of “programmes of care”? Is there any

evidence on the effectiveness of these programmes of care for the defined target

groups?

Third question

What are good practices examples of the integrated rehabilitative health care

approaches in other countries? Which financing models for the care of the target

groups of chronic complex patients are used in the “good practice” countries?


6 Evidence Based Mental Health Services KCE reports 144

Fourth question

What recommendations can be formulated on the organisation and financing of health

care for chronic complex psychiatric patients? How can the available knowledge be

translated to the Belgian health care policy and health services field of mental health

care?

Following the research questions, the basic methodologies used in this report will be:

1. a literature search based on the principles of EBM, reviewing scientific evidence on

mental health care organisation in general as well as continuity of care, care programs

and integrated care more specifically;

2. a description of relevant topics of mental health care organisation in other Western

countries, based on available literature including information from grey sources e.g.

websites, as well as on consultation of foreign experts.

For practical reasons, this report contains two parts: 1. literature review. 2.

international comparison.


KCE Reports 144 Evidence Based Mental Health Services 7

2 GENERAL BACKGROUND: DEFINITIONS

AND SCOPE OF THE STUDY

The main focus of this study is on how mental health care should be organised for the

group of “chronic and complex” mental disorders, and more specifically what the role

can be for “continuity of care”, “programmes of care” or an integrated health care

approach.

The next paragraphs will specify the definitions and the limitations used in this study.

First, a definition will be given for “mental disorder” and for “a chronic and complex

mental disorder”.

Next, it was felt that it was necessary to look for a valid construct to order the various

types of mental health care organisation. Using a comprehensive classification system of

mental health services (a “mental health services typology”) will ensure that it is

complete and relevant.

Third, the general perspective for outcome evaluation is defined; and it is explained

what are relevant outcome domains to take into consideration.

2.1 CHRONIC AND COMPLEX MENTAL DISORDERS:

DEFINITIONS AND SCOPE OF THE STUDY

2.1.1 Definition: Mental disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the

American Psychiatric Association, is the handbook used most often in diagnosing mental

disorders. According to the authors of the DSM-IV-TR (Diagnostic and Statistical

Manual of Mental Disorders, fourth Edition, Text Revision) 1 , a “mental disorder” can be

defined as follows: “a clinically significant behavioural or psychological syndrome or

pattern that occurs in an individual and that is associated with present distress (e.g. a

painful symptom) or disability (i.e. impairment in one or more important areas of

functioning) or with significantly increased risk of suffering death, pain, disability, or an

important loss of freedom. In addition, this syndrome or pattern must not be merely an

expectable and culturally sanctioned response to a particular event, for example the

death of a loved one. Whatever its original cause, it must currently be considered a

manifestation of a behavioural or biological dysfunction in the individual. Neither deviant

behaviour (e.g. political, religious or sexual) nor conflicts that are primarily between the

individual and society are mental disorders unless the deviance or conflict is a symptom

of a dysfunction in the individual, as described above”.

The fifth chapter of the ICD-10 a , containing the WHO's International Classification of

Mental and Behavioural Disorders, defines mental disorders as: ‘the existence of a

clinically recognizable set of symptoms or behaviour, associated in most cases with

distress and with interference with personal functions”. In the introduction of the

previous version, the ICD-9, it is mentioned that for the description of some contents,

there was a collaboration with the authors of the DSM.

In the introduction of the ICD-10, the issue of terminology is brought along. It is

proposed to use “mental disorder” rather than “mental illness” or “mental disease”,

because the first expression has a more neutral connotation than the other ones.

In this study, the term “mental disorder” will preferably be used.

Many caregivers conceptualize mental disorders based on other models. However, it

was beyond the purpose of this study to conduct an exhaustive review on existing

definitions of “mental disorders”.

a http://www.who.int/classifications/apps/icd/icd10online/


8 Evidence Based Mental Health Services KCE reports 144

2.1.2 Definition: “Chronic” or “severe and persistent” mental disorders

Chronic diseases theoretically are diseases which have one or more of the following

characteristics: they are permanent, leave residual disability, are caused by nonreversible

pathological alteration, require special training of the patient for

rehabilitation, or may be expected to require a long period of supervision, observation,

or care. (Dictionary of Health Services Management, 2d ed)

For chronic and/or complex or severe mental disorders so far no generally accepted

definition exists. Currently, most authors prefer the expression “severe and persistent”

to the word “chronic”, which is felt to have a negative connotation. According to the

scientific literature (see overview KCE-report n°84), the definition of “severe and

persistent” psychiatric patients most commonly includes 3 components (DDD):

“diagnosis”, “disability” or severity of illness (or degree of functional impairment) along

the spectrum of a certain diagnosis, and “duration” of illness. Recently, the importance

of “disability” over “diagnosis” is stressed by some authors (e.g. Ruggeri 2000) 2 . In 1997,

Slade 3 proposed five components (SIDDD), by adding “safety” and “formal/informal

support”.

Nevertheless, these considerations are still largely theoretical. In the large majority of

the published scientific papers discussed in the literature review of this report,

inclusion criteria for the group of severe and persistent mentally disordered patients are

limited to the medical diagnosis and eventually the duration of the disorder (see

further). This limits so far the available scientific evidence as to the disability-concept. In

the grey literature, the concept of “disability” is used more often.

As to the “duration” of the disorder, a previous report (KCE-report n° 84) mentions

limits in the literature between 6 months and 2, 3 or even 5 years as cut-off in the

definition of “severe and persistent psychiatric patient”. A difficulty remains that in some

publications duration of illness is taken into account, and in other duration since the

first contact with professional help.

2.1.3 Additional limitations of the scope of this study

The main focus of this study was put on adults (18-65 years). Mental health care for

elderly and children implies specific aspects related to age, and often their needs are

taken care of in separate organisational units.

In this report, substance abuse and addiction will only be dealt with when combined

with another psychiatric diagnosis (the so-called “dual diagnosis” patients). This is in

line with the practical application of the term “severe mental illness” throughout most

of the scientific literature (see Part 1 Literature review). Forensic psychiatry is not

included because of the overlap with service provision in the domain of jurisdiction and

criminology.

In this report, especially in the literature review, a minimum of six months’ duration of

illness was considered to be an indication of “chronic” or “severe and persistent”

pathology, in case of doubt whether a certain publication could be considered to deal

with “chronic” or “severe and persistent” psychiatric patients or not. This is in line with

the lower limit for duration as defined in the KCE-report n°84.

Further limits are defined in 2.2.4.


KCE Reports 144 Evidence Based Mental Health Services 9

2.2 ORGANISATIONAL FORMS OF PSYCHIATRIC CARE:

DEFINITIONS AND SCOPE OF THE STUDY

2.2.1 Introduction

In the following paragraph, a definition is given for the concept of “mental health

services”.

Next, a (comprehensive) classification system of mental health services (a “mental

health services typology”) is searched for. This classification system will be used as a

general frame work, to avoid omissions in the literature search and to have some

common (though certainly imperfect) and preferably quantifiable basis to start from in

the international comparison.

2.2.2 Definition: Mental health service

Clear definitions of “Mental Health Service” are rare. Only in some of the documents

retrieved to find a “mental health service typology” (see further), a clear definition of

this concept is given. The WHO defines mental health services (MHS) as “the means by

which effective interventions for mental health are delivered” b . In the paper on the

development of the WHO-ICMHC (2000) by de Jong 4 a definition is given for

“psychiatric care” and for “psychiatric rehabilitation”. Johnson S, Kuhlmann R and the

EPCAT group 5, 6 defined MHS as follows (2000):

”All facilities which have as a specific aim some aspect of the management of mental

illness and of the clinical and social difficulties related to it. Facilities provided by health

service, social services, voluntary sector and private sectors are to be included. Generic

services which are important for many mentally ill people, but not planned with their

specific needs in mind (e.g. generic facilities for the homeless, offices dealing with welfare

benefits) are excluded. Primary care facilities not specializing in mental health care are

excluded, as are services whose sole purpose is provision of counselling or

psychotherapy, except where they explicitly identify as major target groups individuals

with severe mental illnesses such as schizophrenia or those who are in contact with

secondary mental health services.”

In this study, the word “service” will be used for “facility”, and not for “content of

interventions”.

2.2.3 Typology of mental health services

2.2.3.1 Typology of mental health services: search strategy

Medline was searched (June 2007) using the Mesh-terms “mental health services” and

“classification” and the free term “development”. In a second search, the limit “review”

was added to the same two Mesh-terms. Of the 79 publications retrieved in the first

search and the 102 publications retrieved in the second search, 5 respectively 4 were

considered to be related to the subject of the study, based on Title and Abstract.

Further reading of the full articles revealed that only two articles actually described a

comprehensive classification system for mental health services in developed countries:

the ESMS (European Service Mapping Schedule, 2000) 5 and the WHO-ICMHC

(International Classification of Mental Health Care, 2000) (see further) 4 . A third

reference 7 described the European Socio-Demographic Schedule or “ESDS”, an

instrument identifying a set of socio-demographic characteristics which, on the basis of

currently available evidence, are associated with an increase of psychiatric morbidity;

but this is beyond the scope of this report. References of the described publications

were searched for additional information and one more publication was retained 6 .

b http://www.who.int/mental_health/resources/en/Organization.pdf


10 Evidence Based Mental Health Services KCE reports 144

Because some tools used in organisation and management of health services are not

published in databases like Medline, other sources (grey literature) were looked for.

Websites from organisations known for their involvement in public health and health

organisation worldwide, e.g. WHO, were searched for “Mental Health Services” (Full

list of websites: see appendix). Books on this topic were consulted 8, 9 . Finally, the search

terms “Mental Health Services AND International Comparison” were used in Google,

whereby after the first five pages no more relevant information was found. Overall, a

total of 5 references to mental health services classification systems were found in the

grey literature.

2.2.3.2 Typology of mental health services: results

Types of classification systems for mental health care

Johnson described 6 in 1998 in her survey on European mental health services

classifications, 4 main subgroups:

• classification systems meant to be an inventory or taxonomy of mental health

services;

• classifications based on style and theoretical basis of mental health programs;

• classifications based on description of the precise content of interventions

delivered within a programme or facility;

• methods of studying which focus particularly on the links (“networks”) which

individual services of mental health care have with one another.

In the same paper it has been recognised that prior to comparing the precise content of

different services, a decision needs to be taken whether the services are similar enough

in their purposes to be comparable, and hence a taxonomy of mental health services is

necessary. The same is true for the description of “networks” between different

services.

Since the purpose of this study is to provide information to the government, rather than

to health care providers, it seems not appropriate to look for classification systems

based on the background of the provided therapy, but rather to look for general

inventories or taxonomies of mental health services. Even so, although it proved to be

difficult to gather information on existing mental health facilities in the studied countries

(see further), it would have been even more difficult to gather information on the

precise content of interventions delivered within a programme or facility.

Inventory classification systems for mental health services

The search strategy describe previously (paragraph 2.2.3.1) yielded 9 inventory systems

for mental health services.

In the overview of Johnson 6 et al in 1998, taxonomies available at that time are

described. Only two provide an inventory of all services types, including hospital as well

as community services. The first, proposed by the CSAGC in the UK (1995), does not

provide precise definitions of the terms used in the classification. The second on the

other hand, proposed by the WHO in 1987, consists rather of a description of

existing types of facilities in different countries, without really providing a consistent

framework.

The WHO-AIMS version 2.2 (2005) is designed for low- and middle-income

countries c , so its use in Belgium might not be relevant.

Another WHO-instrument d , described in 2003, makes a general subdivision in

mental health services in primary health care, community-based mental health services,

and mental hospital institutional services; each category has two subdivisions. However,

it is clearly stated in the text that it is only “an attempt to describe various types of

services” and has not been validated.

c http://www.who.int/mental_health/evidence/AIMS_WHO_2_2.pdf

d http://www.who.int/mental_health/resources/en/Organization.pdf


KCE Reports 144 Evidence Based Mental Health Services 11

In a 2005 policy paper of the European Observatory on Health Systems and

Policies e , the following subdivision is used:

• primary care

• mainstream mental health care

o outpatient/ambulatory clinics

o community mental health teams

o acute inpatient care

o long-term community-based residential care

o work and occupational services

• specialized mental health services (e.g. highly specialized services for people

with eating disorders or a dual diagnosis, assertive community treatment

(ACT), sheltered or independent living arrangements).

Whereas the first level should be available in all countries, the second level should be

available in middle-income countries and the third level in high-income countries like

Belgium. The purpose of this classification is not to be comprehensive, but rather to

map broadly the variety of services in different countries.

The “Basic service profile” was developed by Thornicroft and Tansella 9 and is more

comprehensive, but not validated. The main categories are: out-patient and community

services, acute in-patient services, longer-term residential services, and services

providing an interface with other services (e.g. social services or welfare benefits).

Other classification systems described in the book of Thornicroft and Tansella 9 are the

two classification systems also found in Medline (the WHO-ICMHC and the ESMS), as

well as the “Spectrum of Care”, developed by the Department of Health in Britain

(1996). The “Spectrum of Care“ has 3 main categories 9 : home-based services, daycare &

out-patient ambulatory services, residential services hospital/non-hospital. Each of these

3 categories is subdivided in 2 other categories: acute/emergency and longterm/continuing

care. The core components of each level are describedf . The system is

developed to be used in the British National Health Service (NHS).

The WHO-ICMHC (International Classification of Mental Health Care,

2000) 4 does not belong to the category of taxonomies for mental health services, but

rather to the category of classifications based on description of the content of

interventions delivered within a programme or facility (see higher). It contains 10

modalities , e.g. psychological interventions, psychopharmalogical and other somatic

interventions, taking over daily living activities, care coordination etc. (for details see

Appendix). A definition for each of the modalities is given. The use of the scale takes

place in three steps: identifying the module of care to be classified - classifying the

module(s) of care according to qualitative aspects i.e. the 10 modalities - rating the

extent of provision of each modality in each module (4-level scale). Data on

psychometric properties (inter-rater reliability) are available. The WHO-ICMHC and

the ESMS are considered as complementary.

The ESMS (European Service Mapping Schedule, 2000) 5 provides a service

mapping tree (see Appendix) with a total of 4 basic categories and 33 subtypes of

services. Each category and subdivision is well described in a glossary. The second

section of the schedule provides a protocol for making quantitative assessments of

service use per 100 000 population for each of the service types. The system was tested

for inter-rater reliability; and tested for use in several European countries. The 4 basic

categories are:

• Residential (secure, acute or non-acute); including time limited and indefinite

stay;

• day & structured activity (acute or non-acute); including work, work-related

activity, other structured activity and social support;

e http://www.euro.who.int/observatory/Publications/20050126_1

f http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005877


12 Evidence Based Mental Health Services KCE reports 144

• outpatient & community (emergency or continuing care)

• self-help and non-professional help.

2.2.3.3 Typology of mental health services: conclusion

Only one taxonomy for classification of mental health services in highly developed

countries has been tested and validated for use in several countries: the ESMS. This

system will be used as a general frame work in this study, to avoid omissions in the

literature search and to have some common (though certainly imperfect) quantifiable

basis to start from in the international comparison of organisational types of psychiatric

care.

2.2.4 Additional limitations of the scope of this study

Given this typology, some more limits are added to paragraph 2.1.3. Because the KCEreport

n°84 has dealt with organisational aspects of inpatient mental health care, the

literature review of the current report especially focuses on aspects related to semiresidential

care, outpatient and community care, and day activities or work-related

issues. Self-help and non-professional activities are excluded as well.

2.3 OUTCOME EVALUATION: GENERAL PERSPECTIVE

In this report, several outcome domains were taken into consideration, and classified

along five main categories (see also Appendix to chapter 3, evidence tables):

• service utilisation

• clinical outcome (measuring general or disease specific physical health status

including general psychological well-being and cognition (IQ))

• disability and handicap (role functioning focussing on ability to perform

activities of daily life)

• social outcome (social functioning)

• quality of life or patient/carer satisfaction with care (generic or disease

specific)

This classification respects the WHO International Classification of Functioning,

Disability and Health (ICF), which is the translation of the world-wide accepted WHO

bio-psycho-social model g into the field of rehabilitation and chronic care.

The same subdivisions have been recognised in 2 systematic reviews on outcome

measurement in psychiatry, one by CRD (Centre for Reviews and Dissemination,

2003) 10 and one by Slade (2002) 11

The classification into several domains as proposed for this study, has also been applied

in many handbooks on rating scales and questionnaires to measure health (e.g.

“Measuring Health” by Ian McDowell, 2006; “Measuring Health” by Ann Bowling,

2005) 12, 13 . Note that ”general psychological well-being” usually is considered as a

separate category, but that the overlap with disease specific scales for mental disorders

has been mentioned (“Measuring Health” by Ian McDowell, 2006, p 208); in this report

these two categories are taken together.

g http://www.who.int/classifications/icf/site/beginners/bg.pdf


KCE Reports 144 Evidence Based Mental Health Services 13

2.4 EVIDENCE-BASED HEALTH SERVICES RESEARCH AND

HEALTH CARE POLICY

The main target of this report concerns organisational aspects of mental health care,

especially mental health care for persons with severe and persistent mental disorders.

The purpose is to gather “evidence” around this subject.

It deserves to be discussed as to what type of evidence is aimed at.

2.4.1.1 Evidence based Medicine

In the 1970s and 1980s, the concept of “evidence-based medicine (EBM)” was gradually

spread worldwide. Its purpose was to improve the quality of medical decision-making by

allowing practitioners to use more easily the ever increasing amount of available

scientific information. At the same time, it was an attempt to de-emphasize the need to

rely on intuition, authority and subjectivity (Zarkovich 2002) 14 .

In 1996, Sackett defined EBM as: “…the conscientious, explicit, and judicious use of

current best evidence in making decisions about the care of individual patients”

(Dobrow 2004) 15 . After many waves of adaptation, the full concept is now described as

“patient-centred care based on the best available evidence”, including the following

three points: first, the entire decision process should be subjected to full scientific

scrutiny whatever the nature of the evidence or individual clinical experience; second,

interventions should be justified on economic as well as on clinical grounds (costeffectiveness);

third: interventions should incorporate the values and preferences of

both the individual patient and the wider society (preference-driven medicine)

(Greenhalgh 1997, Rycroft-Malone 2004) 16, 17 . Indeed, it is recognised that context–

specific factors can and should play an important role in medical decision-making.

Whereas the primary source of justification for clinical decision-making is based on

quantitative or deductive reasoning (like in experimental trials), context-specific factors

often can better be evaluated by qualitative research using inductive methods (such as

surveys or focus groups) (Greenhalgh 1997). Both types of evidence should be

rigorously evaluated using their own scientific methods, to judge their quality and

scientific merits.

Many authors nowadays admit that quantitative and qualitative evidence can be seen as

complementary and should be integrated (Knapp 2007, Dobrow2004, Rose 2006,

Rycroft-Malone 2004) 15, 17-19 . This also implies that the choice for one or another type of

research should be adapted according to the type of research question for which an

answer is sought. One possible classification of questions and corresponding research

types is given by Jenkins et al (in: Knapp et al. 2007) (see fig): e.g. when the research

question concerns effectiveness and cost-effectiveness, the preferential research type is

the RCT. On the other hand, to evaluate intervention acceptability (“will there be a

demand for this intervention?”) or satisfaction, qualitative research is more apt.

2.4.1.2 Evidence based Health services research

The main focus of this report is on “mental health care organisation”. The relationship

between “health care organisation” and “health care outcome” is a complex one, and

the research involved in this kind of questions belongs to the domain of “health services

research (HSR)”. Indeed, a better understanding of the influence of organisational forms

and organisational regimes on outcome is one of the future challenges for the evidence

research agenda (Anthony 2003; Priebe 2002) 8, 20 .

Literature reviews in HSR, as it is recognized in many papers, are characterized by

heterogeneity of the evidence, and quantitative as well as qualitative research should be

included (Greenhalgh 2005) 21 . Moreover, it is recognized that formal protocol-driven

search strategies may fail to identify important evidence, and that informal approaches

including browsing and “asking around” can substantially increase the yield of search

efforts (Greenhalgh 2005). The KCE HSR methodological procedure note (ref website)

indeed recognize that HSR requires a multitude of research types.


14 Evidence Based Mental Health Services KCE reports 144

It advises to make use of several databases and several types of information including

grey literature and expert consultation when conducting HSR, all depending on the

research question; however all sources used should be well-documented.

Golder et al (2008) 22 recognize the difficulty in developing a valuable search strategy in

this type of literature review, because there is often a wide range of potentially useful

databases and a lack of standardized terminology. Searching a large number of databases

with broad search strategies might identify most of the relevant publications, but might

also yield a large numbers of irrelevant records.

The CRD (Centre for Reviews and Dissemination) guidance for undertaking reviews in

health care (2009) h treats qualitative and quantitative evidence as complementary; with

the qualitative evidence offering an explanation for, and interpretation of, the

quantitative findings. Qualitative findings can help explain, interpret and implement

findings from effectiveness reviews. According to CRD, the main reason why this socalled

“mixed-method” is used increasingly in primary health care research, is to

enhance relevance in the decision-making process, by shaping questions of importance

to end users, understanding heterogeneous results, identifying factors that impact on

the implementation of an intervention etc.

In concluding on evidence about health services there is a need to integrate several

types of evidence, e.g. social science evidence and clinical outcome research. As also

pointed out by CRD, this integration also requires new models of research synthesis;

several techniques to combine quantitative and qualitative data exist (e.g. realist

synthesis, critical interpretive synthesis) (Mays 2005; Dixon-Woods 2005) 23, 24 . A

common practice is that researchers include qualitative data embedded in quantitative

research, but it has been advocated that ideally a separate quantitative and qualitative

review are undertaken (“parallel synthesis”) which are then brought together.

Hence, a more or less ‘classical’ search of the peer-reviewed literature, as was

undertaken in this report, can be considered to be only one part of what ideally should

have been the scope of the literature review . Insofar as interventions in the realm of

(mental) health care organisation can also be considered as a “social construction”, in

which contextual factors tend to take an overriding influence, the discussion rapidly

becomes a sociological one, bringing up fundamental societal choices. This KCE report

does not have the ambition of addressing the latter comprehensively, and did not

perform a separate search to find qualitative research, although qualitative research

papers and/or comments found occasionally were also included. On the other hand, it is

not sure that an extra search for qualitative literature would have yielded much

additional information to support decision-making in mental health care organisation; a

first impression is that it would not.

Besides a literature review, an cross-country international comparison also often

belongs to the field of HSR, and is also part of this report. Whereas data collection

relies on the same principles as the literature review, data from grey literature and

informal contacts usually become much more important due to the scarcity of peerreviewed

publications. For potentially relevant topics to include, the KCE process notes

refer to the WHO 2007 publication i that provides a template for health systems

analysis.

h http://www.york.ac.uk/inst/crd/report4.htm

i http://www.euro.who.int/Document/E88699.pdf


KCE Reports 144 Evidence Based Mental Health Services 15

2.4.1.3 Evidence based Policy

Across all sectors of public policy, there is an increasing recognition of the need to take

account of evidence in the decision-making process. This is named “evidence-based

policy (EBP)”, or sometimes “evidence-informed policy” (Knapp 2007) 18 . When moving

from EBM to EBP, the decision-making context shifts from the individual-clinical level to

the population-policy level. Since consequences of decisions directly affect larger

numbers of people, a clear knowledge of the “mean” effectiveness of a certain

intervention as measured by RCTs becomes even more important (Upshur 2001) 25 . Yet,

if studies are only selected, based on the RCT-research design principles, there will be a

tendency towards interventions with a medical rather than a social or organisational

focus. Similar arguments have been developed in the debate on issues related to health

inequality policies (Asthana 2006) 26 . Selecting information of RCT as a source of

evidence will strengthen the role of pharmacotherapy, compared to social and

psychological interventions (Slade 2001, Tanenbaum 2003) 27, 28 .

On the other hand, contextual issues to take into account in EBP are much broader and

include a demographic, political, economical, social, institutional context etc. (Knapp

2007) 18 . Knowledge of the specific local situation, e.g. cultural patterns or accessibility of

specific services is mandatory. Policy making typically considers the view of many

different stakeholders. Consequently, it is important in EBP to consider various views

and “multiple perspectives” on the same sort of evidence, such as the perspective of

service users, of professionals, of informal carers, of the policy makers themselves

(Rose 2006) 19 . As a further consequence, normative and ethical debates are as

important as clinical cost-effectiveness issues: e.g. the deinstitutionalisation movement

has the characteristics of a social movement. It was a normative, ethical and

destigmatisation choice to integrate people with mental disorders into society.

Integration of all these types of evidence and all the different perspectives is necessary

to respond to the needs of policy makers.

2.4.1.4 Evidence: scope in this report

This report deals with evidence on organisational aspects of mental health care.

Goldman et al (2000) 29 describe two different types of evidence that apply to the field of

organisational aspects in mental health care. The first type is “clinical services research”. In

this type, it is difficult to distinguish completely the treatment intervention from the

organisational strategy, and the treatment is embedded in and/or identified with a

particular organisational strategy (e.g. case management, assertive community

treatment, residential treatment). The unit of analysis is the individual. The second type

is “service systems research”. Service systems strategies work at the organisational level,

often employing financial incentives or regulatory efforts, attempting to alter programs

and policies to support improved care for groups of patients (e.g. what are appropriate

roles for primary care providers and for specialty care providers respectively?).

Whereas both types of research can inform on the contribution of the organisation of

services on health, the second type is less available in mental health care organisation

than the “clinical services research”.

There is no denial that classical EBM-type research has to play an important role in

informing on how mental health services should best be organised. But a broad

analytical perspective is needed. In order to understand the applicability of certain

models, it is essential to take into account the complexity of factors affecting the

organisation models.

A specific difficulty arising in many publications is the lack of precise information on the

provided services, or the use of a similar term for services that may or may not provide

the same the same things (e.g. Burns 2001, Catty 2002) 30, 31 ; a phenomenon sometimes

called the “black box” intervention. This lack of precise information on the services

model can have major implications for interpreting “evidence” related to outcomes.


16 Evidence Based Mental Health Services KCE reports 144

In this report, the basic databases searched were the Cochrane databases of systematic

reviews, CRD database, Medline, Embase, and PsycInfo. As to the type of studies,

(systematic) reviews and meta-analyses (if available), randomized controlled trials,

controlled clinical trials, cohort studies and case-control studies were retained.

References of the retrieved references were scrutinized, and experts were consulted to

inform on important publications that were missed.

Consequently, limitations to this search strategy are the fact that sociological databases

(e.g. Social Sciences Citation Index (SSCI)) were not included, which might yield another

type of publications e.g. a higher number of studies based on qualitative research. On

the other hand, a first impression is that an extra search in these databases would not

have yielded much additional publications appropriate for this study. Also, no attempt

was undertaken to include other sources of information than peer-reviewed

publications, e.g. grey literature.

When reading this report, these limitations should be kept in mind. Besides, in another

KCE-report we will evaluate a Belgian programme which attempted to stimulate a

wealth of therapeutic approaches centred around organisational innovations.


KCE Reports 144 Evidence Based Mental Health Services 17

Table: Matrix of evidence and corresponding research type (source: Knapp et al: Mental health policy and practice across Europe (2007) 18 )


18 Evidence Based Mental Health Services KCE reports 144

3 LITERATURE REVIEW: METHODOLOGY

3.1 INTRODUCTION

3.1.1 European Service Mapping Schedule (ESMS)

In order to make sure that the literature search would be comprehensive, it was

performed starting from a basic typology for which the ESMS (European Service

Mapping Schedule) had been chosen, an instrument for the description and classification

of mental health services (Johnson et al 2000) 5 (see chapter 2). The Service Tree of the

ESMS is shown in the Appendix. Each ESMS subdivision is defined in the ESMS-Manual.

3.1.2 Types of study to be included

As to the study type, meta-analyses, (systematic) reviews, randomized controlled trials,

controlled clinical trials, cohort studies and case-control studies were included, since it

was estimated that focussing on (systematic) reviews and RCTs only might be too

restrictive for the subject under evaluation (organization of mental health care).

Apart from classical EBM j type publications, and although not specifically looked for,

qualitative research was also taken into account when it resulted from the performed

search strategy. Also, when qualitative studies were reported in other types of

publications (e.g. in an RCT or an observational study), it was taken into account.

3.2 SEARCH STRATEGY, IN- AND EXCLUSIONCRITERIA

The following databases were searched:

• -Cochrane Database of Systematic Reviews; CRD Database (CRD-reports,

DARE, HTA)

• -Medline (Ovid); PsycInfo; Embase

3.2.1 Cochrane Database of Systematic Reviews and CRD Database (CRDreports,

DARE, HTA)

For the search in the Cochrane Database of Systematic Reviews (July 2007) and the

CRD Database (CRD-reports, DARE, HTA) (July 2007), the following terms were

crossed:

• -mental* ill* or mental* disorder* or psychiatr*

• -severe* or persistent* or chronic*

Applying the main in- and exclusion criteria (see further), 26 results were obtained in

the Cochrane database and the CRD-database.

To make sure no important systematic reviews would be missed, a second round-up of

the Cochrane library was performed in Nov 2009.

j EBM: evidence based medicine, see chapter 2


KCE Reports 144 Evidence Based Mental Health Services 19

3.2.2 Medline (Ovid), PsycInfo, Embase.

3.2.2.1 Reference retrieval

For each ESMS subdivision, a separate search question was introduced by looking for

appropriate thesaurus terms and supplementary free terms. Examples of search

strategies are presented in the Appendix to chapter 3; the full search strategies can be

obtained from the authors on request.

Most search questions were limited to the years 1997-2007, because most of the

important, already retrieved literature reviews or meta-analyses (Cochrane or CRD

database) went back to 1997 (or 1998) for their literature review. If a high quality

literature review or meta-analysis of a later date was available, only studies from that

date on were included. When still too many search results for one search question

were obtained, the search was further limited to studies concerning adults (18-65

years).

Finally, the reference list of all included studies was looked through for additional

publications relevant to the research question.

To make sure no important references had been missed, a second, independent

researcher developed another search strategy (Medline), which was compared with the

search strategy of the first researcher (see Appendix to chapter 3).

Because of the importance of “care pathways” and “care networks” for this report, an

additional search has been performed on these topics (Nov 2009).

3.2.2.2 Reference evaluation

In- and exclusion criteria

For the theoretical background, see chapter 2.

Further specification of inclusion criteria:

Some indication that it concerned “chronic” or “severe and persistent” mental

disorders had to be present.

Only studies in peer-reviewed journals were taken into consideration.

In publications type EBM (Evidence Based Medicine), outcome had to be evaluated by

quantifiable variables like days of hospitalisation etc., or by means of at least one

validated, peer-reviewed outcome instrument (rating scale or questionnaire) on one of

the 5 domains specified above (see chapter 2). It should also be noted that many scales

or questionnaires contain items of several domains and not just of one single domain.

Further specification of exclusion criteria:

Studies concerning outcome effects/assessment of care for the chronically mentally ill,

not including studies concerning medication trials or studies concerning content of

specific forms of individual therapy (delivered from face to face).

Studies focussing on family interventions or patient/family education were not included,

since this was considered to be a certain form of therapy.

Studies on alcohol or substance abuse were excluded, unless patients with dual

diagnoses were considered (mental health disorder and alcohol/substance abuse) (see

also 2.1.3).

Studies on aspects of forensic psychiatry and issues involving jurisdiction were excluded

because of the overlap with service provision in the domain of justice (see also 2.1.3).

Studies on adults with intellectual disabilities and psychiatric disorders, as well as on

post-partum mother-and-child services were excluded, because it was felt that a more

specific search strategy might be necessary to retrieve all relevant publications. Studies

on prevention, including prevention of suicide, were excluded.


20 Evidence Based Mental Health Services KCE reports 144

All studies describing longitudinal assessment of SMI persons discharged because of

asylum closure were excluded, since this topic has been dealt with in KCE report n°84,

and by now the scientific literature considers these results to be well-established.

Studies dealing with issues on inpatient care are not included since they are subject of

the KCE report 84 (see also 2.2.4).

Studies on self-help and non-professional services are excluded as well.

Studies conducted in developing countries were excluded.

Studies on cost or focussing on economic aspects were not included.

Further details: see Appendix to chapter 3.

Critical appraisal of the literature

First, articles retrieved through the Medline, PsycInfo or Embase search were sifted on

content of title and abstract, according to the defined in- and exclusion criteria. The

studies retained for full evaluation were then summarized using a template or reference

evaluation sheet template (see Appendix to chapter 3). The quality was assessed

according to the Dutch Cochrane checklists (see website Cebam: www.cebam.be). The

results of the qualitative research was evaluated according to the quality of the

reporting of the research strategy, results, context and eventually interpretation.

Next, the level of clinical evidence was assessed according to the system proposed by

Guyatt et al.(2006) 32 . Evaluation of the level of evidence was not applied to individual

studies, but to the body of evidence relating to a specific research question or literature

topic.

The level of evidence according to Gyatt can be:

• High: further research is very unlikely to change our confidence in the

estimate of effect

• Moderate: further research is likely to have an important impact on our

confidence in the estimate of the effect

• Low/very low: further research is very likely to have an important impact on

our confidence in the estimate of effect and is likely to change the estimate;

or any estimate of effect is very uncertain.

3.2.2.3 Flow chart of reference selection for Medline, PsycInfo, and Embase

Flow chart for Medline(Ovid), PsycInfo, and Embase (1997-2007)(excluding

Cochrane/CRD):

• The search strategies used yielded a total of 4837 references. Of these, 647

were retained based on Title/abstract and after discarding doubles.

• When comparing with the Medline search strategy of the independent second

researcher, no references to be included had been missed.

• Finally, after full-text evaluation and after hand-searching reference lists of the

included publications, 58 references were retained for inclusion in the review

(see Summary tables in Appendix to chapter 3).

• The additional search strategies for “care pathways” and “care networks”

(Nov 2009) yielded only one extra study for inclusion in the review.


KCE Reports 144 Evidence Based Mental Health Services 21

4 LITERATURE REVIEW: RESULTS

In this chapter, the first paragraph will define some important concepts. For these

definitions, no separate literature review has been undertaken. They are derived from

the publications retrieved in the general literature review (see chapter 3) or from

references of these publications. This does mean that other authors might use or prefer

other definitions for the same concepts. However, throughout this report the

definitions below are used in a consistent way.

From the second paragraph onwards, the results of the literature search are presented,

and the organizational diversity of the mental health services retrieved from the

literature is stratified according to the ESMS classification. The ESMS subcategory under

concern, is named in the title of the paragraph, and is for each paragraph illustrated by

the figure below the title. Next, the (systematic) reviews retrieved by the search

mentioned under 3.2.1 (Cochrane, CRD) on this subcategory are mentioned, followed

by additional studies retrieved by the systematic search in Medline, PsycInfo and Embase

(see 3.2.2).

After the different subcategories of the ESMS have been discussed, a paragraph is added

on “Continuity of care, services & systems integration” (paragraph 4.5). This paragraph

is added because it spans the different ESMS categories, and because it is a special

matter of interest for this study (see chapter 1 “Research questions”.)

Finally, a general discussion is presented.

4.1 DEFINITIONS

4.1.1.1 Case management

In the MeSH-tree of PubMed (Medline), case management is defined as follows: “A

traditional term for all the activities which a physician or other health care professional

normally performs to insure the coordination of the medical services required by a

patient. It also, when used in connection with managed care, covers all the activities of

evaluating the patient, planning treatment, referral, and follow-up so that care is

continuous and comprehensive and payment for the care is obtained”.

In the 1960s, societal changes led to the political choice to care for the severely

mentally ill in the community. Large psychiatric hospitals were closed down and people

were treated in outpatient clinics, day centres or community mental health centres.

Sharply rising readmission rates soon indicated that this type of community care was

less effective than anticipated. Community services were losing contact with patients

and failing to meet their complex needs. Case management is a means of co-ordinating

the care of severely mentally ill people in the community, arising in the late 1970s as a

response to the problems described above (Marshall, Cochrane review Case

Management, 1998).

Case management is often confused with Assertive Community Treatment (ACT), an

approach which evolved at the same time (see definition of ACT)

In its simplest form (referred to as ’brokerage’) case management is a means of coordinating

services. Each mentally ill person is assigned a ’case manager’ who is

expected to:

(i) assess that person’s needs; (ii) develop a care plan; (iii) arrange for suitable care to be

provided; (iv) monitor the quality of the care provided; and, (v) maintain contact with

the person.

’Brokerage’ case managers often lack clinical qualifications and tend to work outside

established psychiatric services. The basic ’brokerage model’ has evolved into more

sophisticated, but poorly defined, models. Clinical Case Management emphasises the

professional status and therapeutic skills of the case manager and tends to have a

’psychodynamic’ basis; particular importance is placed on the healing power of the

therapeutic relationship between the case manager and ’client’.


22 Evidence Based Mental Health Services KCE reports 144

Intensive Case Management emphasises the importance of small caseloads and high

intensity input, but is otherwise not clearly defined. Strengths Case Management

emphasises are working with the client’s skills rather than deficits. Mostly case

management is practiced at varying levels of intensity and combining elements of the

brokerage, clinical case management, and strengths models.

Rather than describing discrete models, Thornicroft proposed 12 dimensions that could

be used to distinguish case management programs (Ziguras 2000) 33 .

In practice, especially the terms Intensive case management (ICM) and ACT at times

appear to be used loosely and interchangeably, the term ICM being more used in the

34, 35

UK and ACT more in the USA (Smith 2007, Fiander 2003)

4.1.1.2 Assertive Community Treatment (ACT)

According to Marshall (Cochrane review, 1998) 36 , Assertive Community Treatment

(ACT) is an approach which evolved at the same time as case management. Case

management and ACT share the same goals, to: (i) keep people in contact with services;

(ii) reduce the frequency and duration of hospital admissions (and hence costs); and (iii)

improve outcome, especially social functioning and quality of life. Despite a superficial

similarity, important distinctions can be made between case management and ACT.

Under case management great emphasis is placed on individual responsibility of case

managers for ’clients’. ACT, by contrast, emphasises team working. ACT teams attempt

to provide necessary interventions themselves (rather than referring clients to other

providers or agencies); preferably in ’clients’ own homes or places of work. ACT teams

always work with low staff to client ratios (usually 10-15 patients per member) and

invariably practice ’assertive outreach’, meaning that they continue to contact and offer

services to reluctant or uncooperative ’clients’. ACT teams also place particular

emphasis on medication compliance and 24 hour emergency cover. ACT should be

practised according to a defined and validated model, based on a consensus (1995) of an

international panel of ACT experts (for more details, see Thornicroft 1999) 37 .

4.1.1.3 Assertive outreach teams

In England, “Assertive outreach teams” (AOT) aim to provide care to SMI persons

whose needs are difficult to meet by the community mental health teams (CMHTs, see

further). Priebe et al. (2003) 38 evaluated 24 AOT in London and concluded that they

appeared to work much in an ACT-like way although there was a wide variation in their

practices. In the UK study by Ford et al (2001) 39 , the term “assertive outreach” is more

close to the concept of case management.

4.1.1.4 Community Mental Health Teams (CMHTs)

Community Mental health Teams (CMHTs) also evolved in the sixties (MacMillan

1963) 40 A description of its actual content long time remained rather general:

assessment and care less focused on hospital/institutional settings, offering a range of

interventions tailored to the patient’s specific needs and usually provided by a

multidisciplinary team (Malone 2007) 40 . Nowadays, the activities of the community

mental health team often become supplemented by a range of specialised teams, such as

assertive community treatment or assertive outreach, early intervention services for

psychosis and crisis resolution teams (Cochrane, Malone 2007) 40 . A definition for the

“original” generic CMHT has been provided by Thornicroft: “A multidisciplinary team of

mental health staff which has a lead responsibility for the provision of specialist

assessment, treatment and care to a defined population, often defined by geographical

catchment area or primary care registration. Such a team will usually provide the full

range of functions necessary at the specialist care level, including initial assessment of

adult patients referred from other agencies and teams, consultation to primary care staff

on the management of patients, the initial provision of treatment during the onset of a

disorder or the early stages of a relapse, and the continuing care of patients with longer

term disabilities.” Distinctions include: crisis intervention is usually a 24 hr service,

assertive community treatment works on the basis of restricted case loads and early

intervention restricts its focus to patients in the early stages of their illness, usually a

psychotic one.


KCE Reports 144 Evidence Based Mental Health Services 23

Thornicroft was also the first to describe 7 subtypes of CMHTs existing at that time

(1999) in the UK, based on their association (or not) with an ACT team, crisis/acute

home treatment interventions, and/or specialist teams for particular subgroups of

patients 37 . This makes clear that in practice, there is an astonishing variety in how

CMHTs are implemented, at least in the UK.

4.1.1.5 Shared care; shared patient-doctor decision making

In the Cochrane review on shared care in chronic disease management (2007) 41 , Smith

et al. refer to Hickman et al (1994) 42 for the definition of shared care. In this publication,

shared care has been defined as the joint participation of primary care physicians and

specialist care physicians in the planned delivery of care for patients with a chronic

condition, based on an enhanced information exchange over and above routine

discharge and referral (Hickman 1994). It has been used in the management of many

chronic conditions, particularly diabetes. Theoretically, shared care presents an

opportunity to provide patients with the benefits of specialist intervention combined

with continuity of care and management of co-morbidity from generalists who maintain

a responsibility for all aspects of the patient’s healthcare beyond the specified chronic

disease.

Shared care systems frequently include pre-specified clinical protocols, referral

guidelines, continuing education of participating clinicians, specifically designed

information exchange systems and ongoing audit and evaluation of services delivered. It

should provide an opportunity for structured, ongoing clinical management of the

specified chronic disease from both sets of providers.

A taxonomy of shared care for chronic disease was created following a survey of shared

health care in the UK (Hickman 1994) 42 . This suggested that shared care systems may

be defined in the following ways:

1. Community clinics: specialists attend or run a clinic in a primary- care setting with

primary-care personnel. Communication is informal and depends on the specialists and

primary-care team members meeting on site

2. Basic model: a specific, regular communication system is set up between specialty and

primary care. This may be enhanced by an administrator who organizes appointments

and follows up and recalls defaulters from care

3. Liaison: a liaison meeting attended by specialists and the primary- care team where

the ongoing management of patients within the service is discussed and planned

4. Shared care record card: a more formal arrangement for information sharing where

an agreed data set is entered onto a record card which is usually carried by the patient

5. Computer-assisted shared care and electronic mail: a data set is agreed upon and

collected in both the specialty and primary-care setting and is circulated between the

two sectors using computer systems such as a central repository or email. This system

may also include centrally coordinated computerised registration and recall of patients.

6. Other: the authors of the Cochrane review on shared care (Smith 2007) 41 notice

that, since the development of this taxonomy, most “shared care” interventions became

more complex and multifaceted, so that they would have to be classified in the category

“other”.

As will be noticed, some authors prefer the term “collaborative care” instead of

“shared care” when discussing liaison services (e.g. Craven 2006 and Mitchell 2002) 43, 44 .

Another aspect of care provision that has been described is shared or joined patientdoctor

decision making. This aspect does not correspond to the definition of “Shared

care” as defined above. To make it more complicated, some authors also refer to this as

“collaborative care” (Bauer 2006) 45, 46 ; others call it “shared decision making” or

“integrated care” (Malm 2003) 47 . In this report it will be called “shared patient-doctor

decision making”.


24 Evidence Based Mental Health Services KCE reports 144

4.1.1.6 Integrated care

Existing definitions

The term ”services integration” has been used broadly to refer to a range of service

delivery initiatives aimed at improving outcomes for people with complex needs. An

important assumption underlying this concept is that categorically structured (nonintegrated)

human service delivery systems are less able to address the needs of people

with complicated problems. The goals of integration are to provide comprehensive

services; to improve access to these services; to improve continuity of care; and to

reduce service duplication, inefficiency and costs.(Randolph 1997) 48 . Ultimately, better

service integration should lead to an improved clinical status and better quality of life for

the person with mental illness (Durbin 2006) 49 .

The concept of services integration is not easy; and it contains several aspects that are

to be elucidated and included when defining this concept 48, 49 .

A. First, services integration can be defined in terms of the service system level toward

which activities are directed. This can be the “direct service delivery” level (for

individual clients e.g. integration by case management), or the “service systems” level

(for a defined population as a whole, e.g. program integration, integration at the statelevel

etc.).

B. Second, services integration can be viewed as a continuum, that varies in terms of

intensity (ranging from loosely organised alliances to highly integrated organizations) and

in terms of formality of governance (from informal, verbal agreements to formal

procedures and rules).

C. Third, keeping the 2 previous levels in mind, five levels of integration have been

proposed:

1. information sharing and communication;

2. cooperation and coordination: more organized efforts to work together e.g. joint

planning, joint applications, verbal agreements for client referral;

3. collaboration: written agreements or formal procedures defining how different

agencies work together to achieve a shared goal;

4. consolidation: different agencies are reorganized under one organization but

continue to operate independently; the organizational structure facilitates sharing

of information, coordination or collaboration while maintaining agency

autonomy;

5. integration: one organization, a single authority and pooled funding, including a

comprehensive range of services that can be accessed by a single

application/assessment and that provides individualized client services.

The Systems integration logic model

How service delivery initiatives aiming at integration theoretically can lead to better

patient outcomes, and which intermediates presumably are to be taken into account,

has been clarified in the “Systems integration logic model” (Durbin 2006) 49 , shown in

Figure. E.g. Improved continuity of care is presumed to be a vehicle through which

systems integration improvement affects patient outcomes.

In Fig, in the first box the system components are described: governance (how are

responsibilities defined? who makes final decisions?), sector composition (which types of

services are provided?) and available resources. The second box presumes investigation

of the way the system functions: are different service types provided so that

comprehensiveness can be assured? how (intensively) are the different services and

agencies linked? which mechanisms (e.g. centralized admission procedure, …) are put in

place to guarantee service integration? The third box assumes that the effects of service

integration are mediated by 2 intermediates, which should be measured as well:

continuity of care and system accessibility.


KCE Reports 144 Evidence Based Mental Health Services 25

In the fourth box, the final result of the service integration program should be measured

at the patient level and along multiple dimensions (clinical symptoms, functioning in

society, quality of life…). According to Durbin et al, these four steps are all influenced

by the context of the community and this context also influences the final patient

outcomes. E.g. in a community context of a high level of unemployment, less results can

be expected from efforts to integrate vocational rehabilitation into the general service

supply for SMI.

Fig: the Systems integration logic model (Durbin 2006) 49 .

Durbin et al (2006) 49 mention a series of indicators that might be used to evaluate the

degree of systems integration. Examples are: centralized telephone number, single set of

admission procedures, inter-agency treatment teams, shared treatment protocols, etc.

Inter-organizational network ratings are another way to characterize level of systems

integration.

The relationship between “integrated care” and “care networks” will be explained

further (see 4.1.1.7)

4.1.1.7 Continuity of care

Existing definitions

So far, no uniformly accepted definition of “Continuity of care” (CC) exists is in the

literature on mental health care. We therefore mention the different aspects of this

concept that we encountered in the literature review we conducted.

When discussing the definition of “Continuity of care” in mental health services, reviews

usually go back to the definition of Bachrach 50 in 1981. Bachrach defined CC as “the

orderly uninterrupted movement of clients among the diverse elements of the service

delivery system”, and he recognized 7 dimensions: longitudinal nature- individually

tailored- comprehensiveness- flexibility- relationship- accessibility- communication

(Bachrach 1981, Joyce 2004) 50, 51 . In the next developmental phase of the CC concept, it

becomes almost impossible to distinguish it from interventions such as case

management or ACT, since these interventions were basically developed to improve

the continuity of care (Adair 2003) 52 .


26 Evidence Based Mental Health Services KCE reports 144

A next important landmark is the “state of the science” given by Johnson et al. (1997) 53 ,

on “continuity of care” for severely mentally ill persons. Johnson distinguishes the

following aspects of CC for SMI persons:

1. Cross-sectional:

• receipt of a comprehensive range of services in accordance with needs:

o continuity between service providers (degree of communication between

agencies and professionals involved in the patient’s care),

o comprehensiveness (the range of services provided to meet the patient’s

needs),

o accessibility of services (distance to facilities).

2. Longitudinal:

• sustained contact with services and providers over time:

o continuity of contact (provision of out-reaching care to stay in contact

with patients),

o continuity of service provider (patients receive services across time from

the same staff),

o implementation of service plans,

o continuity through discharges and transfers (flexible and rapid transfer

between care levels according to varying needs of patients).

In 2000, Freeman et al (Crawford 2004) 54, 55 mention the importance to add patients’

views of the care they receive.

In 2004, Crawford et al combine the view of Johnson 53 and Freeman 54, 55 , and base their

review of CC for mental health care on the following 5 aspects:

• A: longitudinal continuity:

o (1) patient remains in contact with services;

o (2) no breaks in service delivery;

o (3) patient sees the same member of staff;

• B: cross-sectional continuity:

o (4) different components of health and social care are coordinated;

• C: experiences users and carers:

o (5) service users experience care as smooth and uninterrupted.

Joyce et al (2004) 51 recognize 6 domains in the concept of CC, based on a thorough

qualitative evaluation of the literature on CC for SMI persons and on additional

interviews of SMI persons. These 6 domains largely correspond to the different aspects

mentioned by Bachrach and by Johnson et al (see above); it are:

• linkages between services,

• comprehensiveness of services,

• accessibility,

• patient-provider relationship,

• degree of individualized care,

• flexibility of service location.

Whereas the previous authors focussed especially on CC in mental health care,

Haggerty et al 56 in 2003 evaluate the concept of CC as it is used across the full range of

different healthcare disciplines (primary and specialty health care, nursing,...). They

notice that in many health care disciplines, patients are increasingly seen by an array of

providers in a wide variety of organisations, raising concerns about fragmentation of

care. Policy reports and charters worldwide urge a concerted effort to enhance

continuity, but efforts to describe the problem or formulate solutions are complicated

by the lack of consensus on the definition of continuity.


KCE Reports 144 Evidence Based Mental Health Services 27

Therefore, the authors conducted a systematic literature review on the concept of

continuity in health care; 19% of the references referred to CC in mental health care.

They distinguished 3 types of continuity across all different disciplines of health care:

• informational continuity: the use of information on past events and personal

circumstances to make current care appropriate;

• management continuity: a consistent and coherent approach to the

management of a health condition that is responsive to a patient’s changing

needs;

• relational continuity: an ongoing therapeutic relationship between a patient

and one or more providers.

Haggerty adds that mental healthcare literature especially stresses the importance of a

stable patient-professional relationship over time, and that this relationship is typically

established with a team rather than a single professional.

Related aspects

Crawford et al (2004) 54 and Adair et al (2003) 52 recognize that CC might be influenced

by factors at the individual (patient-related) level, program level or system level.

To evaluate CC, several scales have been developed, and their application field and validity

has been commented on in Reid et al (2002) k . The Alberta continuity of services scale

for mental health (ACSS-MH) is worth to be mentioned. The ACSS-MH has been

developed in 2004 starting from the conceptual analysis presented by Joyce et al 51 (see

above); this scale incorporates the patient’s perspective as well as an independent

(observer-rated) component; the psychometric properties of this scale have been

documented clearly.

According to many authors (Adair 2005) 57 , outcome scales to measure whether CC is

associated with a better outcome should be multidimensional. Indeed, most authors

acknowledge that CC is a complex, multidimensional process that occurs at the

interfaces of multiple services in the trajectory of a patient’s care and according to his

changing needs.

Often, continuity of care is linked to integrated care; see also the Service integration logic

model in Fig (see above) defined by Durbin et al 49 . According to Goldman et al. 1994 58

two fundamental principles are necessary to realize continuity of care are: integration of

hospital and community services; and sectorization (responsibility of service delivery for

a described catchment area).

4.1.1.8 Care Networks

A network of services can be defined as a collection of services which may vary in their

activities or organization, but which share a common mission, operate in a more or less

planned and collaborative manner, and participate in an overall coordinating or planning

body or authority to which each has a degree of accountability (Kates N et al, 1993) 59 .

In a theoretical background to networks, Goodwin (2004) 60 includes the concepts

“pattern of ties or links” and “accountability”; Perry (2006) 61 defines networks on 2

continuums (social regulation and social integration); each network can be characterized

by a certain degree of social regulation (hierarchy, accountability) and a certain degree

of social integration (strength of binds between individuals belonging to the network)(

Van den Holen 2008) 61 .

k Defusing the confusion: concepts and measurements of continuity of healthcare. Reid R, Haggerty J,

McKendry R (2002). Prepared for the Canadian Health Services Research Foundation, the Canadian

Institute for Health Information, and the Advisory Committee on Health Services of the

Federal/Provincial/Territorial Deputy Ministers of Health. http://www.chsrf.ca/home_e.php


28 Evidence Based Mental Health Services KCE reports 144

According to ANAES (2004) l , care networks aim to improve access to care, to improve

care coordination, and to facilitate inter-disciplinary care for a subgroup of patients,

disorders or services; care networks should provide individually tailored care including

diagnosis and treatment as well as prevention and patient education. Besides quality

improvement, cost-effectiveness has also been mentioned as a potential advantage of

care networks (Van de Holen 2008) 61 .

In practice, the term “care network” is often used interchangeably with “integrated

care” (see 4.1.1.5). However, the concept “integrated care” is much broader. Goodwin

(2008) 62 comments on this relationship, and recognizes “care networks” as one means

or form of infrastructure to promote integrated care.

4.1.1.9 Care pathways

“Care programs” and “Care pathways” in mental health care clearly belong to the focus

of the main questions for this report formulated by the Belgian Government. A specific

search (summer 2007; repeated in June Nov 2009 because of the importance for the

report) followed by selection through the main in- and exclusion criteria, yielded no

results for “Care programs”, and only one review for “Care pathways” (Evans-Lacko

2008) 63 .

Evans-Lacko et al (2008) 63 defined a Care pathway (or clinical pathway) as a concept

that applies to “a proposed sequence of steps for clinical care for a particular group of

patients”. Given the specific context of mental health care, where the clinical course of

the disorder can vary considerably, this could be put also as: “a whole of activities in the

provision of clinical care for a particular group of persons with a mental disorder”.

4.2 MENTAL HEALTH SERVICES, RESIDENTIAL, NON-

HOSPITAL

4.2.1 Mental Health Services, Residential, Acute, Non-hospital.

European Service Mapping Schedule (ESMS): (see ESMS tree)

Mental Health Services – Residential – Acute - Non-hospital.

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

l www.anaes.fr

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

Indefinite stay


KCE Reports 144 Evidence Based Mental Health Services 29

A. Cochrane and CRD database

No references retrieved

B. Medline, PsycInfo, Embase

In 1998, Fenton et al 64 published the results of a RCT including 115 SMI persons in

crisis. They were randomised to the acute psychiatric ward of a general hospital, or to

crisis treatment in a eight-bed community residency with 24h supervision but

continuation of their usual community rehabilitation or activities (work…). Staff of the

community residency was not medically trained (as opposed to staff in a day-hospital)

but were supervised by the residency psychiatrist; whereas medication prescription

continued by the patient's usual outpatient psychiatrist. The results of these two

treatment sites were not significantly different for outcomes at discharge and after 6

months in the domains of symptom improvement, psychosocial functioning, acute care

service utilization, patient treatment satisfaction and patient satisfaction with life. Length

of stay was significantly longer in the eight-bed community residency (average number

of days 18.7 versus 11.7). Additional research is necessary to confirm these results.

4.2.2 Mental Health Services, Residential, Non-acute, Non-hospital, Indefinite

stay (Daily support, 24h-support, Lower than daily support).

European Service Mapping Schedule (ESMS): (see ESMS tree)

Mental Health Services, Residential, Non-acute, Non-hospital, Indefinite stay

(Daily support, 24h-support, or lower than daily support).

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

A. Cochrane and CRD database

Indefinite stay

Cochrane Review (2006) by Chilvers et al. “Supported housing for people with severe

mental illness” 65 .

Supported housing schemes (SHS) provide self-contained accommodation on one site,

for people with SMI. Professional staff is on-site and available during office hours at least

for either individual or group social support. Social support may involve counselling,

information, practical help etc. In outreach support schemes (OSS) people with SMI also

live in self-contained accommodation but they do not share a site with other people

with SMI; however they receive regular home visits by professional outreach workers

for individual social support. The aim of the review was to compare SHS with OSS or

’standard care’ for people with severe mental disorder/s living in the community. No

RCTs were identified.

Cochrane Review (2009) by McPherson et al. “Twenty-four hour care for

schizophrenia” 66 .

Twenty-four hour residential rehabilitation (a ’ward-in-a-house’) is one model of care

for SMI persons that has evolved in association with psychiatric hospital closure

programs. Only one trial (UK, 1987) of 22 people and lasting two years was identified.


30 Evidence Based Mental Health Services KCE reports 144

In this trial, persons with SMI lived in a house staffed by professionals who provided 24

hour care; the residents did some domestic work and self-care tasks. Outcomes were

favorable as compared to other forms of community care. It is clear that this single,

small trial does not allow firm conclusions. The authors conclude that currently, the

value of this way of supporting people - which could be considerable - is unclear.

B. Medline, PsycInfo, Embase

A wealth of publications exists on the deinstitutionalization movement in psychiatry,

including many aspects belonging to the ESMS-domain of “Residential, Non-acute, Nonhospital,

Indefinite stay”. As indicated in the methodological part of this report, studies

describing longitudinal assessment of SMI persons discharged because of asylum closure

were not part of this study and were not specifically looked for, since this topic has

been dealt with in the KCE report n° 84, where an evaluation of “Organizational models

as a substitution for long term care in psychiatric hospitals” can be found. Nevertheless,

the publications emerging from the search strategy applied in this report are mentioned

here.

Ogilvie et al (1997) 67 conducted a non-systematic review on supported housing for

persons with SMI. Several qualitative studies were included, with interesting conclusions.

It is clear from many studies evaluating consumers’ preferences that they prefer to live

in their own home and want to live alone. Quality of life of SMI persons is influenced by

multiple factors, one of which is housing type or program. However, social stigma

remains an important factor for people with psychiatric disabilities, affecting community

reintegration; problems to find affordable housing and financial matters are also serious

barriers. Last but not least, there is not a single model for developing and delivering

housing to SMI persons, but the relationship between housing and service supports

seems to be essential. Adequate resources for ensuring services should be in place, and

an appropriate process for coordinating housing and support services.

Fakhoury et al (2002) 68 give an overview of the literature on supported housing. An

extensive search yielded 28 evaluative peer-reviewed studies only, mostly consisting of

cross-sectional surveys, uncontrolled follow-up studies and non-randomized controlled

trials, or direct observation methods; this makes comparative evaluation of effectiveness

difficult. More-over, small study samples and samples confined to small geographic areas

or recruited from a single social agency, limit the generalizability of the results. An

example of this can also be found in the study of Cohen et al 1999 69 (not included in

Fakhoury et al). A narrative overview is given by Fakhoury et al.

A considerable diversity of models of supported housing is found, and different

descriptive terms are used which overlap considerably. There is a continuum

representing different levels of support, as well as different levels of group or

independently living. Two tendencies exist: a more transitional, rehabilitation oriented

approach in which SMI persons move as their abilities to live independent evolve, and a

more maintenance oriented approach where they stay “for life”.

Patient characteristics are likely to predict whether patients live in supported housing

or independently: persons in the former group are more likely to be older, less

educated, and unemployed; they tend to have had longer duration of hospital care and

to have lower daily living skills. Their level of social skills and contacts with family and

friends is likely to be poorer than for independently living SMI persons. Finally, some

characteristics make SMI persons less likely to be accepted in supported housing or

make it impossible for them to live independent: unpredictable aggression, extreme

anti-social behaviour or co-morbid addiction problems.

The overall impression from the studies is that supported housing schemes can have

beneficial effects with moderate to high satisfaction levels reported by most clients.

Several studies underline the importance attached to independent living. However,

problems of isolation and loneliness are reported by some residents.

The authors conclude that future research might try to identify specific features that

discriminate between different settings and contribute to outcomes.


KCE Reports 144 Evidence Based Mental Health Services 31

Two systematic reviews focus on the subgroup of homeless persons with SMI (Nelson G

et al 2007; Hwang S et al 2005) 70, 71 . Both studies make the same conclusions; Nelson et

al also conducted a meta-analysis. They compared the effect on housing stability of

treatment by permanent housing and support, to the effect on housing stability by

Assertive community treatment (ACT, see further) or Intensive case management (ICM,

see further).

Nelson G et al 2007 70 .

Based on 13 experimental and 3 quasi-experimental trials from the USA, the authors

demonstrate significant reductions in homelessness, hospitalization and imprisonment

for homeless people with SMI, resulting from programs that provided permanent housing

and support. This implies permanent housing and single room occupancy although often

some form of group living is included; staff is external to the housing rather than onsite;

and the independent living and support process is controlled by the tenant.

When compared to ACT or ICM, effect size for housing stability was medium for

programs combining housing and support (10 studies, 0.67), medium for ACT alone (4

studies, 0.47) and small for ICM alone (4 studies, 0.28). No significant differences were

found between independent and group housing. Short residential treatment compared

to standard treatment (2 studies) revealed no effect on housing outcome.

The permanent housing and support programs had no consistent effect on clinical

symptoms, social functioning or quality of life compared to standard treatment. On the

contrary, some ACT and ICM studies showed positive effects on psychiatric symptoms.

The effect of ACT on housing stability has also been demonstrated by the ACCESS

study (see further), which was not included in the Nelson review. Further, it can be

concluded from the ACCESS study that integrated care leads to better housing

outcomes as compared to non-integrated care.

McHugo et al (2004) 72 conducted a RCT to evaluate the effect of providing housing and

mental health services in an integrated way to SMI persons at risk for homelessness.

Integrated housing services provided mental health services and housing services by a

single agency, including intensive case management (ICM) and a housing services team.

Parallel housing services provided mental health services by an ACT team, and housing

services by community based landlords. At 18 months follow-up, both groups had spent

significantly more days in stable housing. Participants in the integrated housing services

(IHS) program spent less time homeless (p


32 Evidence Based Mental Health Services KCE reports 144

Key points

• Evidence on supported living outside the old large-scale institutions mostly

consists of uncontrolled follow-up studies, direct observational studies or

other study designs that are prone to methodological flaws.

• The overall impression is nonetheless that supported housing schemes can

have beneficial effects with moderate to high satisfaction levels reported by

most users (see also KCE-report n°84)

• A considerable diversity of models of supported housing is found, and there

is no “one best way”. Rather there is a continuum representing different

levels of support, as well as different levels of group or independent living.

• Well-coordinated housing and supporting services are essential, and enough

resources need to be available to provide services. Further research might

try to identify specific features that contribute to outcomes.

• Qualitative evidence emphasizes that persons with psychiatric disabilities

prefer to live in their own home and want to live alone. Housing type is one

factor that influences their quality of life. However, issues of social stigma,

fear of loneliness and affordability appear to be barriers.

• Some characteristics make SMI persons less apt for supported or

independent living, e.g. unpredictable aggression, extreme anti-social

behaviour or co-morbid addiction problems.

• For homeless SMI persons, providing permanent housing and support can

significantly reduce homelessness, hospitalizations and imprisonment

(moderate level of evidence). It does not influence clinical symptoms, social

outcome or quality of life as compared to standard treatment.

• Providing “housing and support services” in an integrated way to homeless

SMI persons is more effective as compared to non-integrated service

provision. This has also been demonstrated by the ACCESS program (see

further).

• Results of “housing and support programs” are comparable to the effect of

ACT on housing stability; for this group of SMI persons ACT has additional

advantages on clinical symptoms.

4.2.3 Mental Health Services, Residential, Non-acute, Non-hospital, Time

limited stay.

European Service Mapping Schedule (ESMS) (see ESMS tree):

Mental Health Services – Residential - Non-acute - Non-hospital - Time limited stay.

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

Indefinite stay

DAY & STRUCTURED Acute

ACTIVITY

Non-acute High intensity

Low intensity

OUT-PATIENT & Emergency care Mobile

COMMUNITY

Non-mobile

Continuing care Mobile

Non-mobile

SELF-CARE & NON-PROFESSIONAL


KCE Reports 144 Evidence Based Mental Health Services 33

A. Cochrane and CRD database

CRD-review by Drake et al (2008) 34 : A systematic review of psychosocial research on

psychosocial interventions for people with co-occurring severe mental and substance

use disorders.

The focus of this review is the integrated treatment for dually diagnosed patients with

severe mental illnesses and co-occurring substance abuse. Search strategy is not

described, however 8 reviewers evaluated the completeness of the review. Part of the

review deals with residential treatment interventions, a narrative synthesis of 12 quasiexperimental

studies is presented; only one of these had been included in the Cochrane

review by Cleary 73 et al (2007)(see further). Nearly all compared a more integrated with

a less integrated approach, and many studies focussed on homeless dual diagnosis clients

who had not responded to outpatient interventions. Some residential programs were

short term (less than 6 months), other were long term (1 year or more), and 1 study

compared short-term and long-term integrated residential treatment. The study

heterogeneity makes firm conclusions impossible, and results were inconsistent in the

different outcome domains. However, findings on substance abuse were positive for

(subgroups within) the longer term programs. Findings were also positive for the longer

term programs for some medical outcomes and some outcomes on community

functioning, although a diversity of outcome measures was used. The authors concluded

that the integration of substance abuse and mental health treatments seemed to

improve a variety of outcomes, especially longer term residential treatment; but further

research is required since the included studies had several types of methodological

flaws.

B. Medline, PsycInfo, Embase

No additional references retrieved

Key points

• For people with dual diagnosis, i.e. mental disorder and substance abuse, the

current evidence on integrated (mental health care-substance abuse)

residential treatment is inconclusive and more well designed controlled

clinical trials are necessary (low quality evidence)

4.3 MENTAL HEALTH SERVICES, OUT-PATIENT AND

COMMUNITY

4.3.1 Mental Health Services, Out-patient and community, Emergency care

(mobile/ non-mobile).

European Service Mapping Schedule (ESMS): (see ESMS tree)

Mental Health Services - Out-patient and community - Emergency care

(mobile or non-mobile).

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

Indefinite stay


34 Evidence Based Mental Health Services KCE reports 144

A. Cochrane and CRD database

Cochrane review by Irving (2006) 74 “Crisis intervention for people with severe mental

illnesses”.

Five studies were included. Participants were persons with severe mental illness, i.e.

schizophrenia or other serious mental illnesses, however diagnosed; depressive crisis

and substance abuse were excluded. Crisis intervention embedded in multi-disciplinary

home care was evaluated versus acute hospital admission. None of these included

studies purely investigated crisis intervention; all used a form of home care for acutely ill

people, which included elements of crisis intervention. Also, none of the studies claimed

that hospitalization could be entirely avoided; and admission to hospital was not

considered to be a failure of community crisis intervention. Forty five percent of the

crisis/home care group were unable to avoid hospital admission during their treatment

period. Home care may help avoid repeat admissions but these data were

heterogeneous.

No differences in death or mental state outcomes were found (although death might be

a relatively poor informative parameter to judge overall crisis intervention results).

Crisis/home care increases patient adherence, reduces family burden, and is a more

satisfactory form of care for both patients and families. Data on cost effectiveness were

inconclusive. Home care crisis treatment, coupled with an ongoing home care package,

is a viable and acceptable way of treating people with serious mental illnesses. If this

approach is to be widely implemented it would seem that more evaluative studies are

still needed.

Berhe et al (2005) 75 : “Home Treatment für psychische Erkrankungen” (CRD-review

DARE-20054489 in 2007): Literature review: acute care at home as compared to

inpatient treatment is equally or more efficacious in respect to reduction of symptom

distress, social (re-)integration and patient and carer satisfaction. Direct costs for home

treatment were often lower than for inpatient care. However, the number of relevant

studies (six) is limited and knowledge on the long-term effects is sparse.

Weinmann et al (2005) 76 .

This systematic review, including SRs, RCTs and CCTs up to 2003, describes the results

of the Cochrane review (Irving 2006).

B. Medline, PsycInfo, Embase

No additional references retrieved

Key points

• There is evidence of moderate quality that home care crisis treatment,

provided within other ongoing home care services, is an acceptable way of

treating people with serious mental illnesses. No difference in death or

mental health state is found as compared to acute hospital admission, but

more studies, especially on long-term effects, are necessary.

• Crisis home care reduces family burden and is a more satisfactory form of

care for both patients and families.

• It is not claimed that hospitalization can be entirely avoided; and admission

to hospital should not considered to be a failure of community crisis

intervention. Probably about half of the crisis home care patients are unable

to avoid hospital admission at a certain point during follow-up, but further

studies are necessary.


KCE Reports 144 Evidence Based Mental Health Services 35

4.3.2 Mental Health Services, Out-patient and community, Continuing care.

European Service Mapping Schedule (ESMS): (see ESMS tree)

Mental Health Services – Out-patient & community – Continuing care

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

Indefinite stay

The publications for this ESMS subdivision (paragraph 4.3.2) will be further classified as

follows:

1. Community mental health care: efficacy/effectiveness

2. Case management: efficacy/effectiveness

3. Assertive community treatment: efficacy/effectiveness

4. Dual diagnosis: mental disorder and co-occurring substance abuse:

efficacy/effectiveness of integrated community care

4.3.2.1 Community mental health care: efficacy/effectiveness

A. Cochrane and CRD database

Cochrane review by Malone et al. (2007) 40 : “Community mental health teams (CMHTs)

for people with severe mental illnesses and disordered personality.”

Community mental health care for people with severe mental illnesses, provided by a

multidisciplinary team, was compared to usual care, i.e. non-team community care,

outpatient care (ambulatory care organized at an hospital), admission to hospital, or day

hospital. When at the same time ACT (assertive community treatment) or casemanagement

was provided the study was not included. Participants were persons with

severe mental illness, however defined in the included studies. Three studies (587

patients) were included, they all had been conducted in the UK.

CMHT management did not reveal any statistically significant difference in death by

suicide. Significantly fewer people in the CMHT group were dissatisfied with services

compared with those receiving standard care (RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to

11). Also, hospital admission rates were significantly lower in the CMHT group (RR 0.81

CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to

emergency services, contact with primary care or with social services did not reveal any

statistical difference between comparison groups. Community mental health team

management is not inferior to non-team standard care in any important respects and is

superior in promoting greater acceptance of treatment.

It may also be superior in reducing hospital admission. The authors conclude that this

evidence should be confirmed by other studies.

The results of the 2 following Cochrane reviews that compare day activities (transitional

day hospitals, day hospitals providing day treatment programmes or day care centres)

to usual outpatient care are mentioned in paragraph 4.4.3. (Day and structured

activities), but their results can also be included here:


36 Evidence Based Mental Health Services KCE reports 144

Cochrane review by Shek et al (2009) 77 : “Day hospital versus outpatient care for people

with schizophrenia”

Cochrane review by Catty et al (2007) 78 “Day centres for severe mental illness”

In the first review (Shek 2009), two types of day hospital (or: partial hospitalization

programs) as an alternative to out-patient care (but not inpatient care), are covered:

’day treatment programmes’ and ’transitional’ day hospitals. Day treatment programmes

offer more intense treatment for patients who have failed to respond to out-patient

care (usually patients with affective or personality disorders). Transitional day hospitals

offer time-limited care to patients who have just been discharged from in-patient care.

A third type, ’day care centres’ are included in the second review (Catty 2007); day care

centres offer structured support to patients with long-term severe mental disorders

who would otherwise be treated in the out-patient clinic; they are mostly not run by

hospitals or hospital staff.

It can be concluded from these reviews that insufficient evidence was found to

determine whether day hospitals providing day treatment programmes, transitional day

hospitals or (non-medical) day care centres have advantages over outpatient care for

SMI persons.

Weinmann et al (2005) 76 .

This systematic review, including SRs, RCTs and CCTs up to 2003, describes the results

of 2 Cochrane reviews, and includes the results of the PRiSM-study conducted in the

UK (see next paragraph.)

Burns et al (2001), Catty et al (2002) 30, 31 “Home treatment for mental health problems:

a systematic review”.

This review takes the Cochrane methodology as its starting point, but has a wider remit

than usual, including high-quality non-randomized studies (prospective, with matched or

equivalent groups). Comparative analysis was first conducted with the RCTs alone, and

then repeated including non-RCTs of sufficient rigor. Studies were not confined to the

patient group of severe mental illness: the majority of the participants had to be 18 to

65 years old with a `mental health problem'. Studies of substance abuse were excluded,

except as a dual diagnosis. Home-based care (conducting treatment at home) was

assessed against hospital care and against other forms of outpatient care. “Other forms

of outpatient care” included any service that enables the patient to be treated outside

hospital as far as possible and remain in their usual place of residence; included were

assertive community treatment, intensive case management, case management, training

in community living, and Community Mental Health Team care. The outcome parameter

of interest was “days of hospital care” during follow-up. The meta-analysis was confined

to a total of ninety-one studies, of which 56 were RCTs and 35 controlled studies.

Eighty per cent of the studies had community controls and 20% in-patient controls.

Over a quarter of the studies were carried out in the UK, and over half in the USA. The

study inclusion criteria did not focus on the patient group of severe mental illness; but

87 studies focussed on people with psychotic disorders.

Studies comparing home treatment with in-patient hospital controls found a greater

reduction in the mean number of hospital days during follow-up in favour of home

treatment, than did those comparing home treatment with community controls. For

studies of all duration of any time, there were 3.31 fewer days per patient per month

compared with in-patients, and 0.40 fewer days compared with community controls.

For studies of duration of at least 1 year, the differences were 4.75 days for in-patient

control studies and 0.13 for community controls.

The only service components of home-based care that were significantly associated with

reduced hospital time for community-control studies were 'regularly visiting patients'

and 'responsibility for both health and social care'. The authors concluded that benefit

of home treatment over admission in terms of days hospitalised was clear, but that it

was inconclusive in relation to other community-based alternatives.


KCE Reports 144 Evidence Based Mental Health Services 37

Additionally, a 3-round Delphi exercise ascertained consensus among 11 expert

psychiatrists on the important components of community-based services that enable

them to treat patients outside hospital. Six categories (including 16 items) were

identified: skill-mix, psychiatrist involvement, service management, case load between

15-25, flexible working hours over 7 days (but not necessarily 24-hours), and home visit

(but teams need not to be dedicated to home treatment). The teams in the included

publications were fairly heterogeneous as to these 6 main components.

Of interest is also the comment, made by the authors in 2002 (Burns 2002) 79 , that the

supposed “active ingredients” of effective home interventions overlap with (but are not

identical to) the basic principles of ACT (see also paragraph 4.3.2.3).

It should be kept in mind that most studies were performed in the USA or in the UK,

and local or international contexts can affect extrapolation of findings to different

settings. Therefore, the authors performed separate analyses to compare results for

USA-based versus European-based studies (Burns 2002) 79, 80 . It appeared that USA-based

studies found a larger reduction in hospital days than European-based (mostly UK)

studies, which could not be attributed not to differences between the experimental

service provision in the two parts of the world. It seemed that there was a difference

between the control groups in the USA and Europe, such that European control

services seemed to be closer to experimental services.

It is interesting to note that the authors, who could contact about 60% of the authors of

the included publications, found out that less than 50% of the teams described by these

authors were still identifiable, and less than 25% of the teams were still enduring in

approximately their original form, without having dropped their ‘innovative’ features.

This raises questions as to the sustainability of these services.

B. Medline, PsycInfo, Embase

Whereas the Cochrane study on CMHTs (Malone 2007) 40 focused on the comparison

of CMHTs to non-team mental health care, other aspects of CMHTs were highlighted in

studies not included in the Cochrane evaluation.

PriSM Psychosis Study (1998), see also Weinmann et al (2005)

In this study (Thornicroft 1998, Taylor 1998, Leese 1998, Wykes 1998, Johnson 1998,

Thornicroft and Wykes 1998, Becker 1998) 81-87 , patient outcomes at two UK urban

socio-demographic matched catchment areas (each 40 000 inhabitants) were compared

before and after implementation of a Community mental health service (CMHS). In area

one, the CMHS was an intensive service with two specialist teams (one for acute and

one for continuing care); in area two, it was a standard service with a generic team.

In these catchment areas, a random sample (N=302) of all psychotic (as a proxy for

SMI) persons, their carers and responsible staff were interviewed at baseline (while

psychiatric services were largely provided on a hospital-base) and after two years.

Outcomes were evaluated in the domain of psychiatric symptoms, social functioning and

social networks, (un-)met needs, quality of life and satisfaction with services. Outcomes

for both types of CMHS were better than for the baseline hospital-oriented service. No

evidence was found that community-oriented services (including community in-patients

beds) fail service users, their family or the wider public. This trial confirmed that the

health and social gains reported in experimental trials of CMHS can be replicated in

ordinary clinical settings. When comparing area one and two, some very limited extra

advantages in terms of met needs, improved quality of life and social networks, were

found in the intensive CMHS; but the general CMHS was almost as effective (and less

expensive in the context of the UK service system). It was noted in this study that at

the two catchment areas, only 9% of the included persons were full-time at work.

Killaspy et al (2006) 88 conducted a RCT to compare CMHTs with ACT (see further). In

this study in London, 251 SMI persons were involved. After 18 months, no difference

was found in inpatient bed use or in clinical or social outcomes for the 2 treatment

groups. However, ACT seemed better to keep contact with difficult-to-engage persons,

and client satisfaction with services was greater.


38 Evidence Based Mental Health Services KCE reports 144

UK700 study (Burns 2000): see further

• For people with severe mental illnesses Community mental health team

management is not inferior to non-team standard outpatient or hospital

care and is superior in promoting greater acceptance of treatment. It may

also be superior in reducing hospital admission. However, this evidence

coming from UK trials only should be treated with caution, and further

research is necessary.

• There is insufficient evidence to determine whether day hospitals providing

day treatment programmes, transitional day hospitals or (non-medical) day

care centres have advantages over outpatient care for SMI persons.

• Home-based treatment for mental disorders can reduce the number of days

spent in hospital during follow-up, when compared to hospital based care.

The difference between home-based care and other forms of outpatient care

is less clear. Evidence for this conclusion is of moderate quality.

• Factors associated with this reduction in hospital days for home-based

treatment were “regularly visiting patients” and “responsibility for both

health and social care”.

• At the time of the systematic review on home-based treatment, less than

50% of the teams of the original studies still existed. This raises questions as

to the sustainability of these services.

• Many of the included studies were performed in the USA or the UK, so

extrapolation toward other countries should be done with caution.

4.3.2.2 Case management: efficacy/effectiveness

A. Cochrane and CRD database

Cochrane review by Marshall et al (1998) 89 : “Case management for people with severe

mental disorders.”

Participants were persons with severe mental illness, i.e. schizophrenia and

schizophrenia-like disorders, bipolar disorder, depression with psychotic features, or

dually diagnosed persons (severe mental illness plus substance abuse). Ten studies were

included. When compared to standard community treatment, results showed that case

management increased the numbers remaining in contact with services (OR = 0.70;

99%CI 0.50-0.98; NNT 15) but approximately doubled the numbers admitted to

psychiatric hospital (OR 1.84; 99% CI 1.33-2.57). Case management showed no

significant advantages over standard care on any psychiatric or social variable, except on

compliance (one study). Cost data did not favour case management but insufficient

information was available to permit definitive conclusions.

The authors conclude that case management is an intervention of questionable value, to

the extent that it is doubtful whether it should be offered by community psychiatric

services.

Ziguras et al (2000) 33 : “A meta-analysis of the effectiveness of mental health case

management over 20 years.”

In this meta-analysis, both studies on assertive community treatment (ACT, see further)

and case management were included, since ACT was considered to be a specific kind of

case management. There were no restrictions on study design, other than limiting

inclusion to comparative studies. Studies for which an effect size or p-value could not be

calculated, were excluded from the analysis. Forty-four relevant studies were identified,

including 35 comparisons (29 RCTs) of usual treatment with either assertive community

treatment (19 studies) or another model of case management (16 studies). Nine studies

(7 RCTs) directly compared assertive community treatment with another model of case

management. The approach used for study selection and quality assessment provided

very limited information. Heterogeneity between studies was tested; some evidence of

publication bias was found in the analysis.


KCE Reports 144 Evidence Based Mental Health Services 39

The authors also carried out a sensitivity analysis that excluded non-randomized studies;

the remaining randomized studies were more homogenous and the results were similar

to the overall pooled data.

Assertive community treatment and “standard” case management both led to small to

moderate improvements in the effectiveness of mental health services. The two

approaches had similar effects in improving clinical symptoms, the patient's level of

social functioning, as well as patient and family satisfaction with services. Assertive

community treatment had some demonstrable advantages over clinical case

management in reducing hospitalization, both in terms of the proportion of patients

admitted and the total length of stay. Case management led to more hospital admissions

than usual care, but these admissions were shorter, which also reduced the total

number of hospital days.

Weinmann et al (2005) 76 .

This systematic review, including SRs, RCTs and CCTs up to 2003, describes the results

of the Cochrane review and the review by Ziguras et al (ref), and included also the

results of the UK700-study (see next paragraph)

CRD-review: Gensichen et al (2006) 90 : Case management to improve major depression

in primary health care: a systematic review.

Studies assessing case management as a community-based intervention in primary health

care settings were eligible for inclusion. Thirteen RCTs were included. The complexity

and nature of the interventions varied and was scored by a published complexity score,

examining the number of elements included in the intervention. The review concluded

that case management is an effective strategy in the treatment of major depression in

primary health care settings, improving clinical response, symptom scores and remission

rate.

Overall, the findings appear to support the intervention, but some caution is advised

given the differences between studies. However, the evidence is insufficient to

recommend 'complex' case management over 'standard' case management. The majority

of the studies were conducted in the USA, and further research is required to

investigate the effectiveness of case management in other health care systems.

B. Medline, PsycInfo, Embase

Burns et al (1999), Walsh et al (2001) and Burns et al (2000) 91-93 describe the results of

the UK700-study, a large UK randomized controlled trial comparing standard case

management (SCM, case-load >30) and intensive case management (ICM, case-load 10-

15) for 708 persons diagnosed with psychotic symptoms and SMI (UK700 trial) (ref,

ref). No significant differences were found at 2 year follow-up between the two groups

for rate of suicide, rate or duration of hospital admission, clinical outcome, social

functioning including living independently, days in jail, quality of life, number of unmet

needs, or patient satisfaction with health services. At 1 year follow-up there were

significantly less clinical symptoms and unmet needs in the ICM group, but this had

disappeared by two years. Counter-intuitively, significantly more patients lost contact

with their case manager in ICM than in SCM. Many other studies found differences in

favor of intensive approaches; however this was not confirmed in this trial. The authors

conclude that future investment should aim at the specific content of care rather than at

its form and delivery.

Bjorkman et al (2002) 94 describe the results of a Swedish RCT on case management

(strengths model) versus standard care, including 77 SMI persons. After 36 months, they

found no differences in clinical or social outcome. However, CM was successful in

reducing days spent in hospital, and the clients were also more satisfied with the service

compared to standard care. Bjorkman et al (2007) 95 re-evaluated the initial cohort six

years later, and found a decrease in use of psychiatric services and sustained

improvements in social functioning.


40 Evidence Based Mental Health Services KCE reports 144

Ford R et al (2001) 39 conducted in the UK a multi-site 5-year follow-up study of people

with severe mental illness. From 0 to 18 months all three sites had Intensive Case

Management (ICM) teams practising assertive outreach. From 18 to 60 months one

team sustained ICM, one team merged and another was disbanded. All original ICM

team clients still alive at 60 months FU were the study participants (N=120); no

differences were found between the 3 sites in clinical or social outcome or in number of

clients dropped out of contact with services. The authors conclude that ICM might not

be necessary in the long term since the varied service models appeared to achieve

similar outcomes. Procedures should be developed to transfer people after a certain

time form ICM to lower intensity care.

Key points

• There is moderate quality of evidence that case management can ensure

that more people remain in contact with psychiatric services (one extra

person remains in contact for every 15 people who receive case

management).

• However, it increases hospital admission rates (moderate quality of

evidence); more good quality studies are necessary to judge whether length

of stay diminishes.

• Evidence on its effects in improving clinical symptoms or the patient's level

of social functioning, is conflicting.

• Many forms of case management exist, and the complexity and nature of the

interventions varies. Evidence is insufficient to recommend 'complex' case

management over 'standard' case management.

• The majority of the studies were conducted in the USA or the UK, and

further research is required to investigate the effectiveness of case

management in other health care systems.

4.3.2.3 Assertive community treatment: efficacy/effectiveness

A. Cochrane and CRD database

Cochrane review by Marshall et al (1998) 36 : “Assertive community treatment for people

with severe mental disorders.”

Participants were persons with severe mental illness, however defined in the included

studies. Twenty studies were included. ACT was compared to outpatient clinics or

CMHT (standard community care). People receiving ACT were more likely to remain in

contact with services (OR 0.51, 99%CI 0.37-0.70; NNT=9) and less likely to be

admitted to hospital than those receiving standard community care (OR 0.59, 99%CI

0.41-0.85; NNT=10). Significant and robust differences between ACT and standard

community care were found for accommodation status (living independently, NNT=7),

employment (NNT=7), and also for patient satisfaction (2 studies only). There was no

clear difference between ACT and standard community treatment on the outcomes of

death or clinical symptoms, and of social functioning. ACT was also compared to

hospital-based rehabilitation services delivered to ambulatory patients. Those receiving

ACT were no more likely to remain in contact with services but were significantly less

likely to be admitted to hospital (OR 0.2, 99%CI 0.09-0.46). Those allocated to ACT

were significantly more likely to be living independently (OR 0.19, 99%CI 0.06-0.54).

For the comparison of ACT to case management, there were no data on numbers

remaining in contact with the psychiatric services or on numbers admitted to hospital,

but people allocated to ACT spent fewer days in hospital than those given case

management. There were insufficient data to permit robust comparisons of clinical or

social outcome.


KCE Reports 144 Evidence Based Mental Health Services 41

It should be noted that the publication on this topic of the Danish Institute for Health

Services Research (DSI) (1999) m and “Gezondheidsraad” or the Health Council of the

Netherlands (2004) n are largely based on this Cochrane report.

Conseil d’évaluation des technologies de la santé du Québec (AÉTMIS, 2001) 96 :

“Assertive community for people with persistent and particularly severe mental illness”

In this report, the authors state that ACT is only intended to serve adults with severe

mental illness who have considerable difficulties, most often manifested by psychotic

symptoms, poor response to usual services, and repeated hospitalizations. According to

their estimations, this population represents only 0.7 to 1 person in 1,000 on average –

thus a small minority, 10% at most, of those with severe mental illness. This report also

proposes a number of organizational, technical and financial means to facilitate the

introduction of ACT services in Quebec.

The literature review in this report is based on the Cochrane review (1998), the review

of Mueser et al. (1998) 97 and an older review of Scott LE and Dixon LB (1995). For the

period from 1995 to 1998, a computerized search using Medline, PsycInfo and Embase

was conducted. Experimental and quasi-experimental studies were included, as well as

some references belonging to the “gray literature”. The conclusions of this report are in

agreement with the conclusions of the Cochrane review (Marshall 1998)

Weinmann et al (2005) 76 .

This systematic review, including SRs, RCTs and CCTs up to 2003, describes the results

of the Cochrane review (Marshall M 1998) 36 , and includes also the results of 3 additional

RCTs.

The 3 RCTs describe results after a 2-year follow-up period; the first by Harrison-Read

et al (2002) 98 in London (UK); the second RCT by Clarke et al (2000) 99 in the USA; and

the 3 rd RCT by Dekker et al (2002) 100 was conducted in the Netherlands (Amsterdam).

In the London study (Harrison-Read et al, 2002), no clinical or functional differences are

found between ACT and usual care, despite a 2.4 fold increase in community contacts in

the ACT group.

In the USA-based study by Clarke et al, no differences are found between ACT and

usual care in time to first psychiatric hospitalization, emergency room visit and

homelessness, although the time to first police arrest is increased in the ACT group.

The ACT group consisted of two subgroups: consumer-staffed and non-consumerstaffed

ACT teams. SMI persons from the non-consumer-staffed ACT team experienced

a significantly shorter time to first hospitalization, were more often hospitalized and

visited more often an emergency room. In the study by Dekker et al, the ACT program

reduces strongly the number of days in hospitalization but there is no difference in

every day functioning as compared to usual care. Weinmann et al 76 conclude that these

recent studies show that since the start of ACT in the1970s, some of its principles

might have been passed on to routine care, especially in England.

CRD-review (DARE- 983570 in 2007): Mueser et al (1998) 97

Literature review includes 32 RCT’s on standard case management, rehabilitationoriented

community care, intensive comprehensive care (assertive community

treatment (ACT) and intensive case management (ICM)); however, validity of the

included studies is not assessed. ACT and ICM reduce time in hospital and improve

housing stability, especially among patients that are high service users. ACT and ICM

appear to have moderate effects on improving clinical symptoms and quality of life. Most

studies suggest little effect of ACT and ICM on social functioning, arrests and time spent

in jail, or vocational functioning.

Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in

gains. Research on other models of community care is inconclusive.

Cochrane review by Marshall et al (2009) 101 : “Early intervention for psychosis”

m http://www.dihta.dk/projekter/60_uk.asp

n http://www.gr.nl/adviezen.php?ID=972


42 Evidence Based Mental Health Services KCE reports 144

The onset of psychosis, typically in young adulthood, is usually preceded by a period of

non-psychotic symptoms, known as prodromal symptoms. Early intervention has two

objectives: the first is to prevent the onset of schizophrenia in people with prodromal

symptoms; the second is to provide effective treatment to people in the early stages of

schizophrenia, with the goal of reducing the ultimate severity of the illness. The

Cochrane review included 7 RCTs (literature up to August 2006); none of the studies

had similar interventions. All but one evaluated several treatment options, such as

medication, cognitive behavioural therapy and family therapy against each other or

against usual care; these trials, all including a limited number of participants (less than

83), are out of the scope of this report.

One large study, the Scandinavian OPUS study (Bertelsen 2008) 102 , included 547 first

episode schizophrenia patients and allocated them to “integrated treatment” (ACT plus

family therapy, social skills training and a modified medication regime) or standard care.

Global state outcome GAF significantly favored integrated treatment (n=419, WMD -

3.71 CI -6.7 to -0.7) by one year, but by two years data were non-significant. Rates of

attrition were significantly lower (n=547, RR 0.59 CI 0.4 to 0.8, NNT 9 CI 6 to 18) for

integrated treatment by one and two year follow-up. The authors conclude that

insufficient trials were identified to draw any definitive conclusions.

B. Medline, PsycInfo, Embase

Tibbo et al (1999) 103 conducted a pre-post study of 295 persons with SMI in Canada,

comparing their hospital admissions before and 1 year after their involvement in ACT.

They confirm the conclusions of the Cochrane review, as to reduction of emergency

room visits, hospital admissions and length of stay. The pre-post study by Udechuku et

al (2005) 104 of 43 persons with SMI in Australia also found reduction in readmission

days after the start of ACT. The quality of these 2 studies is weak; they are presented

because they contain an evaluation of ACT in a naturalistic clinical environment.

Smith et al (2007) 35 conducted a systematic review for case management and selected

39 papers on studies conducted between the 1970s and 2002. The large part of the

studies involved Intensive case management (ICM) (15 papers) and ACT (10 papers),

the rest of the experimental conditions were standard CM or other variants of CM. The

terms ICM and ACT appeared often to be used loosely and interchangeably.

Comparators were standard CM, other variants of CM, hospital-based rehabilitation

(one study) and standard care.

The authors described the results qualitatively. The four most commonly described

outcomes were hospital admissions, total days admitted, symptom reduction and quality

of life (QoL). For hospital admissions and total days admitted, the results were not

consistent (decrease, no change or increase). Symptom reduction and QoL were either

improved or there was no significant difference. In the domains of engagement in

therapy, employment, and independent living the results were consistently positive, but

the number of studies examining these outcomes was small (2-5 studies). The authors

observe that the benefits of the experimental conditions over the control conditions

diminished over time. First, as time evolves the control condition more often becomes

“standard CM”. Second, the authors speculate that “standard care” has developed to

resemble CM or ACT. Firm conclusions remain difficult due to poorly defined

treatment conditions in many studies, and because of differences between studies due

to local implementation factors.

The Dutch RCT by Sytema et al (2007) 105 , including 118 SMI persons, confirms the

results of the Smith review, in that the use of in-patient care was not significantly

reduced; neither were there important clinical or functional gains. However, maintaining

contact with difficult to engage SMI persons was improved by ACT as compared to

standard care.


KCE Reports 144 Evidence Based Mental Health Services 43

Burns et al (2007) 106 conducted a meta-regression to explore which factors contribute

most to a decrease in days of hospital admission when Intensive case management ICM

or ACT (terms used interchangeably) is offered to persons with SMI. They conducted a

systematic review and included 29 existing clinical trials. Authors were contacted for

levels of staffing and fidelity rating of the team to the ACT model; for rating of CM

involvement in the control condition, and for initial data-sets. In the meta-regression

analysis these factors were tested on their correlation with decrease in days of hospital

admission; the other factors were the base-rate hospital use and mean days of hospital

use in the control group, the study year (assuming that effects might be more

prominent in older studies), the country (USA or non-USA), and the trial size. Only for

base-rate hospital use (mean days admitted 2 years before the study) or hospital use in

the control groups, and for fidelity to the ACT model, statistical significance was

reached. The result for the latter was less robust in sensitivity analyses. The authors

conclude that ICM/ACT works best when participants tend to use a lot of hospital care

and less when they do not. However, according to Rosen et al (2008), it might be

difficult to conclude firmly on the factor “fidelity to the ACT model” and “levels of

staffing”, since these were based on retrospective fidelity ratings and recall of the

original investigators (Rosen 2008) 107 . The same holds true for “CM in control

treatment”.

Coldwell et al (2007) 108 conducted a systematic literature review and meta-analysis to

evaluate the effectiveness of ACT for homeless people with SMI. Six RCTs (five of

which are also included in Nelson et al (2007) 70 ) and 4 observational pre-post studies

were included, all but 1 study were from the USA. ACT participants experienced

significantly greater success in reducing homelessness (8/10 studies, 4/6 RCTs) but not

in reducing hospitalization (2/5 studies, 1/4 RCTs). ACT participants experienced

significantly larger reduction in psychiatric symptoms (4/6 studies, 2/3 RCTs). The

summary effect size (random effects method) for homelessness (RCTs) is 37% (95%

CI=18-55; p=0.0001); the summary effect size (random effects method) for

symptomatology (RCTs) is 26% (95% CI=7-44; p=0.006). Five of the six included RCTs

are also included in Nelson G 2007 and in Hwang S 2005 (see higher); conclusions are

in line.

Krupa et al (2005) 109 organized focus groups with 52 SMI participants to describe the

perspective of ACT service users in Canada. Overall, participants were positive about

their involvement with ACT and their experiences reflected the critical ingredients that

the model aims at. Based on an intense, continuous one-to-one relationship with a

primary worker and a relationship with the team, ACT helped its service users with

meeting daily practical challenges and it eased the problems associated with living in

poverty on a disability pension. It engaged them in treatment, offered interventions

related to management of the disorder, and supported them in crises. Overall, services

promoting community participating were less well developed than clinical approaches.

Tensions inherent in receiving ACT services were related to the participants’

negotiation of personal and social consequences of mental illness while striving for

autonomy and community participation (e.g. conflicts over medication or money, feeling

stigmatized because of receiving ACT services). According to the service users, staff

required more training in particular service areas, and occasionally authoritative

practices were noticed which should be avoided.


44 Evidence Based Mental Health Services KCE reports 144

C. ACT: General information and discussion

The results of Smith et al (2007) and Weinmann et al (2005) 35, 76 , seem to point to an

evolution over time in outcome results, for both ACT and ICM. Studies conducted in

the 1970s showed overwhelmingly positive findings for the experimental groups over

standard care. Studies conducted since then have had less favourable results with a mix

of improvements in some domains and no significant change in other domains. Likewise,

there seems to be a trend of different experiences of Europeans and North Americans

with ACT and ICM (Burns 2000 and Burns 2001) 80, 92, 110 , with results being less

prominent in European studies 111 , as it was also found for home treatment (see higher,

Burns et al 2002) 79, 80 .

Without being exhaustively, and in line with the issues discussed in paragraph 2.4, an

explanation for this might be that local resources, infrastructure, national policy and

other systemic issues have real interactions with how ACT and ICM are practised.

These factors are no constants and as policy and resources change, there will be

inevitably an impact in clinical settings. This is clearly illustrated by Fioritti et al (2002) 112 ,

who compare an ACT team in Bologna, Italy, with an ACT team in London, UK.

All these factors were explored by Burns et al (2007) 106 in a meta-regression of existing

studies on ICM or ACT for SMI persons; dependent variable was days of hospital

admission. The decrease in days of hospital admission was most strongly associated with

intensity of hospital use before the start of the trial, and was not related to country or

time of study conduct. The factors “fidelity to the ACT-model”, “level of staffing”, or

“use of CM in the control group” relied on retrospective data only and might need

further exploration.

Priebe et al (2003) 38 evaluated the working modalities of Assertive outreach teams

(AOT). In England, the provision of AOT by the CMHTs is obligatory since 1999; they

aim to serve the subgroup of SMI persons whose needs the CMHTs struggle to meet.

Priebe et al conducted semi-structured interviews with 24 AOT in London and

concluded that they appeared to work much in an ACT-like way although there was a

wide variation in their practices. The population these AOT worked with is described.

Commander et al (2005) 113 also describe the 2-year follow-up of a cohort of 250 SMI

persons involved in assertive outreach services in North Birmingham. Note that in the

study of Ford et al (2001) 39 , already discussed before, the term “assertive outreach” is

more close to the concept of case management.

114, 115

Cuddeback et al (2006), van Veldhuizen (2007)

In a narrative review of low quality, an interesting question is raised by Cuddeback et al

(2006) as to how many ACT teams are needed nationwide. The review describes that

many authors agree on the fact that it is not necessary to provide ACT for all persons

with severe and persistent mental illness. Rather, in the context of the USA, ACT

eligibility is typically defined as having a severe and persistent mental illness, and a

minimum of two or, according to some authors, three psychiatric hospitalizations within

the past year. According to Cuddeback, this is estimated at 20 to 50 percent of all

adults with SPMI. The AETMIS review (see before), also estimates that only 10% of SMI

persons need ACT.

On the contrary, van Veldhuizen (2007) argues that, in the context of the Dutch health

care system, a more extensive model of ACT can be beneficial for all persons with SMI,

including those in a more stable illness phase.

The interested reader, who wants to know more on practical and operational issues

concerning ACT, is referred to Phillips et al (2001) 116 .


KCE Reports 144 Evidence Based Mental Health Services 45

Key points

• People receiving ACT are more likely to remain in contact with services as

compared to standard community care but not hospital-based rehabilitation

(moderate quality evidence).

• There is moderate quality of evidence from one Cochrane review (1998)

that ACT, when compared to standard community care or hospital-based

rehabilitation, can reduce hospitalizations in SMI persons.

• However, in more recent studies, control conditions could also include some

form of case management (CM), and results seemed to be less prominent in

European countries as compared to the USA.

• A meta-regression (2007) demonstrated that the variable “days admitted to

the hospital” is dependent on the intensity of hospital use before the start of

the trial: ACT works best when participants tend to use a lot of hospital care

and less when they do not. No relationship with country or year of study (old

or more recent study) was found.

• ACT, compared to standard community care or hospital-based

rehabilitation, can improve accommodation status (living independently)

and employment (moderate quality evidence).

• ACT provides significant better client satisfaction (2 trials); results on quality

of life are divergent.

• There was no clear difference between ACT and standard community

treatment on death, clinical symptoms or social functioning (moderate

quality evidence).

• Available evidence does not suffice to indicate whether ACT teams should

be based in hospitals or in community organizations.

• One qualitative study concludes that overall, SMI persons are positive on

their involvement with ACT.

• One large Scandinavian study on “Early psychosis intervention”

implemented an integrated treatment including ACT, but more evidence it

needed before final conclusions can be made.

4.3.2.4 Dual diagnosis: mental disorder and co-occuring substance abuse:

efficacy/effectiveness of integrated care

A. Cochrane and CRD database

Cochrane Review by Cleary et al (2007) 73 : “Psychosocial treatment programmes for

people with both severe mental illness and substance misuse”.

For a variety of reasons, the frequency of co-occurring substance abuse among people

with severe and persistent mental illness is high. Abuse of drugs or alcohol in this

vulnerable population increases their risk of adverse outcomes, such as non-adherence

to treatment, relapse, suicide, hepatitis and HIV, homelessness etc. Treatment programs

for substance abuse and for mental disorders traditionally differ in their theoretical

underpinnings, protocols, and service supply. Therefore it has been suggested that

providing both therapeutic approaches to “dual-diagnosis” patients in a coordinated way

by integrated services, might yield better results than providing each service separately.

Cleary et al (2007) evaluated 4 RCTs (N=735) on integrated care for substance abuse

and mental disorders, based on the “integrated team” philosophy: the same clinicians or

teams of clinicians provide long-term treatments in a coordinated fashion, which means

that the services should appear seamless to the client with a consistent approach,

philosophy and set of recommendations. More-over, this type of care also included

outreach to engage patients, as described in the ACT model. As compared to usual

care, no difference was noted by 36 months for loss to follow-up (4 studies) or

substance abuse (1 study only) in the integrated program.


46 Evidence Based Mental Health Services KCE reports 144

Two studies demonstrated an equal rate of hospitalization in both groups, and no

difference in stable community residency at 36 months. The authors also described 4

other RCTs (N=151) on intensive case-management (ICM, case-load


KCE Reports 144 Evidence Based Mental Health Services 47

STRUCTURE

Psychiatric day

treatment/care

Employment

service

Table 4.1 Classification of mental health services providing day and/or

structured activity

Alternative to

inpatient admission

Acute psychiatric day

hospital

x x

FUNCTION

Shortening duration

of inpatient stay

Recovery or/and maintenance

Transitional day Day centre (more intensive:

hospital

day treatment; structured

(non-acute) support only: day care)

Vocational program

(supported employment or

pre-vocational training)

Social care facility x x Drop-in centre

4.4.1 Mental Health Services, Day & structured activity, Acute.

European Service Mapping Schedule (ESMS):

Mental Health Services - Day & structured activity – Acute.

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

Indefinite stay

For treatment in day hospitals as compared to inpatient care, systematic reviews as well

as RCTs were found. However, in these publications all types of acute psychiatric

disorders were included and not only SMI persons in need of acute care. Since no

separate evidence is available for the group of SMI persons, the evidence for all types of

acute psychiatric disorders will be presented here.

A. Cochrane and CRD database

CRD-review (DARE-20011271 in 2007): Horvitz-Lennon et al (2001) “Partial versus full

hospitalization for adults in psychiatric distress: a systematic review of the published

literature (1957-1997)” 118 .

These authors included 18 studies on adults (18-65 yrs) in acute psychiatric distress; the

severity of illness in the participants varied widely. Persons with addiction problems

were excluded. The literature search was poorly documented. Study types were 10

RCTs, 4 clinical trials, and 4 studies of another type; 11 studies were of fair and 2 of

poor quality. Several methodological flaws were evident, e.g. lack of baseline

comparability of groups, a mean baseline exclusion rate of 56% for the RCTs, high dropout

rates, heterogeneity of outcome measures etc. Effect sizes for each study were

calculated or mathematically estimated. A meta-analysis was performed on the grouped

studies and sensitivity analyses were performed. For clinical symptoms and social

functioning, there was no difference between full or partial hospitalization in any of the

reported effect measures.


48 Evidence Based Mental Health Services KCE reports 144

In the short term (0-6 months after discharge) partial care appeared to significantly

improve measures of social functioning but this was not retained in the long term (7-12

months or 13-18 months after discharge). Measures of satisfaction with services were in

the advantage of partial care at 12 months after discharge. Given the methodological

flaws, the authors recommended further research to confirm the results.

Cochrane Review by Marshall et al (2003) 119 : “Day hospital versus admission for acute

psychiatric disorders”.

Nine RCTs on adults (18-65 yrs) with acute psychiatric disorders were included;

persons with primary diagnoses of addiction or organic brain disorder were excluded.

Between day hospital patients and controls, there was no difference in number of days

in hospital (n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55); and there was no

significant difference in readmission rates (n=667, 5 RCTs, RR 0.91 CI 0.72 to 1.15).

Psychiatric symptoms of patients in day hospital care improved more quickly (n=407,

Chi-squared 9.66, p=0.002), but this was not the case for social functioning (n=295, Chisquared

0.006, p=0.941).

Combined data suggested that, at the most pessimistic estimate, day hospital treatment

was feasible for 23% (CI 21 to 25) of those currently admitted to inpatient care, and at

best for 38% (CI 35 to 40).

B. Medline, PsycInfo, Embase

Priebe et al (2006) 120 :

This RCT randomized 206 patients with acute psychiatric disorders of any type

(excluding addiction) to conventional in-patient care or treatment in one London day

hospital center. The first admission period of Day hospital patients was significantly

longer, but they were no more likely to be readmitted. Day hospital patients had a

significantly greater reduction in clinical symptoms at discharge even when taking into

account their longer stay; this effect had disappeared 3 respectively 12 months after

discharge. They reported a significantly higher treatment satisfaction at discharge and 3

months later, but there was no difference in quality of life at discharge or during followup.

A limitation of this study is the low response rate at time of discharge (54%). The

authors conclude that acute psychiatric day hospital may be an effective alternative to

conventional in-patient care for patients in acute psychiatric distress (all diagnoses).

Kallert et al (2007) 121 : A multicenter RCT (EDEN-study) was conducted in 5 centers in

different countries: the UK, Germany, Poland, Slovac Republic, Czech Republic. It

studied effectiveness of acute day hospital versus inpatient treatment. Patient inclusion

was not confined to SMI persons, but to all types of mental disorders excluding

addiction; 1117 patients were included. Results show that acute psychiatric day hospital

is as effective as in-patient care on clinical symptomatology, treatment satisfaction and

quality of life. Overall level of treatment satisfaction differed according to the treatment

center. Acute psychiatric day hospital is more effective on social disabilities at discharge

and at 3- and 12-month follow-up. The first admission period was significantly longer for

day hospital patients. In this study, it was estimated that day hospital treatment was

feasible for 17% to 35% of those patients currently admitted to inpatient care. A

separate analysis (Schützwohl 2005) 122 of German data on the burden on relatives (95

participants) did not show differences between day hospital and in-patient treatment.

Fairburn et al (2005) 123 : Treatment of anorexia nervosa (AN) is discussed, based on a

systematic review by NICE on treatment of eating disorders (ref). No empirical

evidence is available to support the use of any one treatment setting (inpatient, day

patient, outpatient) over any other in terms of AN patients’ outcome. The NICE review

made the same conclusions for other types of eating disorders.


KCE Reports 144 Evidence Based Mental Health Services 49

The research strategy used in this report yielded two articles of more recent date than

the NICE review (Kong et al (2005) 124 : RCT, eating disorders, 43 participants, day

treatment versus outpatient treatment; Zeeck 125 et al (2006): case-control study,

anorexia nervosa, 26 participants, day treatment versus inpatient treatment). It is not

possible to drawn further conclusions based on this limited evidence. Moreover, these

disorders can present at adolescence as well as at adulthood. The search strategy used

in this report (18-65 years) might be too limited to deal extensively with this topic.

Discussion

An interesting question has been raised by Marshall (HEN report 2005): “the key issue

in the current debate over acute day hospitals is whether they still have a worthwhile

role compared to more radical alternatives to admission such as crisis intervention and

home based care. There is a clear need for research that focuses on direct comparisons

of acute day hospital care with other alternatives to admission, and explores their role

in modern community-based psychiatric services”.

Key points

• For persons with acute psychiatric stress (all diagnoses), day hospital

treatment can be a valuable alternative to in-patient care.

• Results from several well-conducted trials in different countries and different

health care contexts show that results on clinical symptoms, social recovery,

quality of life and satisfaction with treatment are not worse compared to inpatient

treatment.

• Length of day hospital stay seems to be on average longer than stay on a

ward, but results from available trials are not fully convergent.

• Day hospitalisation is not a valid option for every patient. It is estimated that

day hospital treatment is feasible for 1/5 to 1/3 of those currently admitted

to inpatient care.

• There is a need for research that focuses on direct comparisons of acute day

hospital care with other alternatives to admission such as crisis intervention

and home based care.

4.4.2 Mental Health Services, Day & structured activity, Non-acute, Work or

work-related activity (high & low intensity).

European Service Mapping Schedule (ESMS):

Mental Health Services - Day & structured activity - Non-acute - Work or

work-related activity (high & low intensity).

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

Indefinite stay


50 Evidence Based Mental Health Services KCE reports 144

A. Cochrane and CRD database

Cochrane Review by Crowther et al (2001) 126 : “Vocational rehabilitation for people

with severe mental illness”

People who receive supported employment are significantly more likely to be in

competitive employment than those who receive pre-vocational training, as concluded

from 18 RCTs. At 18 months, 34% of people in Supported Employment were employed

versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI

0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and

worked more hours per month than those in Pre-vocational Training.

CRD review (DARE-970407): Bond et al. (1997) 127 : experimental and non-experimental

studies, qualitative overview: people who receive supported employment are

significantly more likely to be in competitive employment than those who receive prevocational

training.

Weinmann et al (2005) 76

This systematic review, including SRs, RCTs and CCTs up to 2003, describes the results

of the Cochrane review (Crowther 2001), and includes also the results of one

additional RCT by Lehman AF 2002. The latter study was conducted in the USA, and

again emphasizes the advantages of supported employment. The reviews by Bond et al

(2004) 128 and by Twamley et al (2003) 129 (retrieved in the Medlin search) make similar

conclusions.

B. Medline, PsycInfo, Embase

Latimer et al (2006) 130 confirms the results from the reviews in a RCT including 150 SMI

persons conducted in Canada.

Burns et al (2007) 131 performed a large multi-center RCT in 6 different European

centres. In this study 312 SMI persons received IPS (individual placement and support)

or standard vocational services. IPS linked with existing CMHTs in charge of SMI

persons and helped SMI persons that wanted to re-enter in the competitive labour

market to find appropriate employment directly; IPS developed a network of employers

willing to accept patients and supported also these employers. Standard services

included a training program at combating deficits regarding to working skills, followed

by help to find a job. IPS was clearly superior in number of patients starting a job, and in

length of job tenure. SMI persons in the control group were more likely to drop-out.

Local unemployment rates accounted for heterogeneity in the outcomes.

Leff et al (2005) 132 further elaborate on the relative role of several aspects of IPS, in the

context of the US labour market. Cook et al (2005) 133 evaluated 1273 SMI persons

receiving vocational and psychiatric services. Integrated “vocational-psychiatric” services

seemed more effective, but this conclusion might have been confounded by the fact that

less severely involved SMI persons received more vocational services.


KCE Reports 144 Evidence Based Mental Health Services 51

4.4.3 Mental Health Services, Day & structured activity, Non-acute, Other

structured activity, (high & low intensity).

European Service Mapping Schedule (see ESMS):

Mental Health Services - Day & structured activity - Non-acute - Other

structured activity (high & low intensity).

SECURE

RESIDENTIAL Generic acute Hospital

Non-hospital

Non-acute Hospital Time limited

Indefinite stay

Non-hospital Time limited

DAY & STRUCTURED

ACTIVITY

OUT-PATIENT &

COMMUNITY

SELF-CARE & NON-PROFESSIONAL

Acute

Non-acute High intensity

Low intensity

Emergency care Mobile

Non-mobile

Continuing care Mobile

Non-mobile

A. Cochrane and CRD database

Indefinite stay

The results of the following Cochrane review that compares day activities provided in

day care centres to usual outpatient care are also mentioned in paragraph 4.3.2.1

(Community mental health care); the distinction with transitional day hospitals and day

hospitals providing day treatment programmes is described in paragraph 4.4.

Cochrane review by Catty et al (2007) 78 : “Day centres for severe mental illness”.

In this review, all day care centres linked to hospitals were excluded, and only “pure”

non-medical day care centres were taken into account. No trials could be selected,

hence no evidence is available.

B. Medline, PsycInfo, Embase

No additional references

Key points

• Insufficient evidence is available to determine whether day hospitals

providing day treatment or transitional day hospital care have advantages

over outpatient care for people with schizophrenia or other similar mental

illness.

• There is also insufficient evidence to judge on the outcomes of day care

centres for this group of persons.


52 Evidence Based Mental Health Services KCE reports 144

4.4.4 Mental Health Services, Day & structured activity, Non-acute, Social

support, (high & low intensity).

European Service Mapping Schedule (ESMS):

Mental Health Services - Day & structured activity - Non-acute - Social support (high &

low intensity).

A. Cochrane and CRD database

Cochrane review by Buckley et al (2007) 134 : “Supportive therapy for schizophrenia”.

This review defines “supportive therapy” as a therapeutic element, most often (but not

always) classified in the group of psychotherapy. Treatment by face-to-face therapy is

out of scope of this report.

B. Medline, PsycInfo, Embase

No additional references that specifically refer to organizational aspects of social

support (and not to the therapeutic aspect).

4.5 CONTINUITY OF CARE, SERVICES & SYSTEMS

INTEGRATION, CARE PROGRAMS

Although not belonging to the ESMS tree, this paragraph is added because it spans the

different ESMS categories, and because it is a special matter of interest for this study

(see chapter 1 “Research questions”.)

4.5.1 Continuity of care

A. Cochrane and CRD database

No references retrieved

B. Medline, PsycInfo, Embase

The amount of studies addressing the relationship between continuity of care (CC) and

patient outcome for SMI persons, is rather limited and characterized by an enormous

heterogeneity. To understand this, one should keep in mind that continuity of care is a

complex concept comprising many aspects which are not always easy to measure, or to

standardize across studies (see definition of CC). Likewise, patient outcomes ideally

should be measured along several dimensions, and very little studies address a

comprehensive range of outcome parameters. Further, the relationship between service

provision, continuity of care and patient outcomes is probably very complex and

determined by many other factors, which should be taken into account as well. This

makes it very difficult to measure a direct relationship between patient outcomes and

continuity of care.

Nevertheless, an overview of the studies that attempted to address this difficult subject

is given in the next paragraph.

Adair et al (2003) 52 included quasi-experimental, cohort and pre-post studies up to June

2002 in a systematic review about effects of continuity of care (CC) on outcomes for

SMI persons. He concluded that the result from the SR was compromised by the

heterogeneity of the included studies and by the limited aspects of CC that were

measured whereby a diversity of evaluation instruments were used. The evidence on

effects of CC on symptom control, patient functioning and quality of life remained

limited showing positive effects in 2 studies but not in 3 other (among which the largescale

RWJF program, see also next paragraph). Examples of included studies are

Bindman et al (2000) 135 and Saarento et al (1998) 136-139 .

In 2005, a prospective cohort study was performed by Adair et al 57 who evaluated

continuity of care by using a new evaluation instrument, the Alberta continuity of

services scale for mental health (ACSS-MH). This instrument includes a CC evaluation

by a professional as well as by the service user himself. For 486 SMI persons with

stabilized illness, results of the ACSS-MH were compared with patient outcomes.


KCE Reports 144 Evidence Based Mental Health Services 53

A significant association was found between patient-rated continuity (ACSS-MH) and

quality of life, functioning as well as service satisfaction; and between observer-rated

continuity (ACSS-MH) and quality of life as well as service satisfaction (significant at 0.01

level). No association was found with severity of clinical symptoms. However, the

observational nature of the study does not allow to draw definitive conclusions on the

causality of this relationship between CC and quality of life and service satisfaction: it is

possible that persons who have better functioning and quality of life are more capable of

continuity-maintaining behaviors.

Two later published studies on the relationship between patient outcome and CC are

not reported here but are excellent examples of the many difficulties that are

encountered while evaluating this type of interventions (Greenberg 2005, Forchuk

2005) 140-142 ; details can be found in the Appendix. The same holds true for the review by

Klinkenberg et al (1996) 143 (see also Appendix).

Crawford et al (2004) 54 conducted a systematic review of meta-analytic, experimental,

observational and qualitative research, including literature up to Sept 2001. This SR

examined what factors interfere with (promote or hinder) the delivery of continuity of

care for SMI persons. Continuity of care (CC) was defined as: loss-to-follow up, breaks

in service delivery, CC from a particular professional, CC between service components,

service users' perception of CC.

Sixty papers were included. However no quality appraisal of the included papers was

performed, which impairs the quality of this SR. Nevertheless the most important

results are reported below, since Crawford was the only author including qualitative

research on this subject (more details can be found in the Appendix).

Whereas for SMI persons patient-related factors associated with improved CC,

(especially decrease in loss-to-follow-up) are rather well-established, service related

factors have been less studied. Moderate quality of evidence exists only for a decrease in

loss-to-follow-up by service-related interventions such as ACT, case management,

CMHTs and crisis interventions. Whether ACT and case managers lead to more CC

from a particular professional or not, is not known. A moderate level of evidence

comes from a RCT and from several observational studies, that preparing discharge

from hospital by patient training or by contact with an out-patient professional while

still in-patient, improves loss-to-follow-up. Service related factors associated with better

CC between service components are poorly studied, but it seems that effects of one

possible intervention, namely information and training for general practitioners, are not

straight-forward (1 RCT). There is a high level of evidence from a Cochrane review and

one RCT that in the group of SMI-persons shared-care records do not enhance or

facilitate communication. Interesting are the results from 2 qualitative studies (including

30 respectively 16 service users) that conclude that service users' perception of CC is

better if they have the opportunity to build a long-term therapeutic relationship with

one professional, if "contextualising" takes place (which means that professionals who

have known the patient for a long time help other professionals to reframe the

problems in the same way), and if key-workers are willing to adopt a flexible approach

to care.

Conclusion on Continuity of care

Continuity of care is widely considered to be an important element of contemporary

care for mentally disordered persons, especially for those with long-lasting mental

illnesses, and CC measures are even used as performance indicators (Greenberg

2005) 141, 142 . Nevertheless, research to date, which remains of low quality due to implicit

methodological problems, has not shown that continuity of care either by itself or in

interaction with other features of service delivery ultimately improves clients’ well-being

as defined by symptom control, functioning or quality of life.

Whereas measures of CC can be useful in evaluating changes in the process of care,

they are not straightforwardly related to individual outcome.


54 Evidence Based Mental Health Services KCE reports 144

Until recently CC studies mostly used a provider-point of view, but two recent

qualitative studies evaluate CC from the service users’ point of view, including 30

respectively 16 interviewees(Crawford 2004) 54 . They point out that service users'

perception of CC is better if they have the opportunity to build a long-term therapeutic

relationship with one professional, if "contextualising" takes place (which means that

professionals who have known the patient for a long time help other professionals to

reframe the problems in the same way), and if key-workers are willing to adopt a

flexible approach to care.

4.5.2 Services and systems integration

First, two USA-based large multi-centre studies will be discussed that specifically aimed

to clarify the effect of services and systems integration on persons with SMI: the Robert

Wood Johnson Foundation (RWJF) Program and the ACCESS program. One Dutch

study evaluating the effect of care networks on service use is also mentioned.

Next, other reviews and studies evaluating “Shared care” will be discussed, since

“shared care” as defined previously (see chapter 4.1.1.4) can be considered to be a

certain way to realize “services and systems integration”.

4.5.2.1 The Robert Wood Johnson Foundation (RWJF) Program (USA)

In the RWJF program, nine medium-to-large USA cities received subsidies to integrate

care for individuals with chronic mental illness (CMI) through two levels of reorganization

(Lehman 1994, Morrissey 1994, Durbin 2006, Adair 2003) 49, 52, 144, 145 . At the

systems level, a local mental health authority (LMHA) was created to re-organize local

provider agencies across a wide range of sectors (i.e., health, housing, social welfare and

mental health) into a well-functioning network of coordinated services. LMHA had

clinical, administrative and fiscal responsibility. At the services level, case management

programs were implemented to provide CMI persons with individualized assistance to

obtain needed services. One comparison city was included in the evaluations.

First, the performance of the LMHA was evaluated; all sites succeeded rather well in the

creation of a LMHA and ratings of the network structure improved over time. Second,

continuity of care (CC) was compared for 2 cohorts of SMI persons, and level of CC

was compared with evolution in patient outcomes. Patients were included at discharge

from the hospital. Cohort 1 (N=359): discharged during the early stages of the project.

Cohort 2 (N=302): discharged later, after the LMHA was expected to have moved the

system to a higher level of integration. Structured patient interviews at discharge and at

2 and 12 months after discharge asked about symptoms, functioning, quality of life and

about received mental health services. Continuity indicators included having a case

manager; changing case manager; having any service needs; amount of unmet need (i.e.,

needs addressed divided by needs identified); and perceived helpfulness of services. The

expectation was that continuity of care and clinical outcomes would be better for

cohort 2 than cohort 1 clients.

Improvements of CC from cohort 1 to cohort 2 were modest (at 12 months significant

better result for cohort 2 for two CC indicators (p


KCE Reports 144 Evidence Based Mental Health Services 55

4.5.2.2 The ACCESS program (USA)

The ACCESS program (Access to community care and effective services and supports,

USA, 1994-1998) evaluated if greater integration and coordination among agencies

within service systems would improve outcomes among severely mentally ill (SMI)

homeless people (Morrissey JP 2002) 146 . Nine intervention sites received additional

technical support and funding to implement strategies of systems integration (e.g.

integration coordinator position, interagency coordinating body, cross-training, client

tracking systems); matched control sites did not receive this support. Over four years

time, intervention sites implemented a higher number of integration strategies and

achieved an increased integration among service agencies, as calculated based on the

social network method 147 .

The included SMI persons (N=7055) should not yet be involved in community

treatment at baseline. The 18 involved intervention and control sites all received funding

to implement ACT, which was offered to all participants entering the study. From

baseline to follow-up, substantial improvement was observed in mental health (observed

and self-reported signs or symptoms; number of psychiatric or service contacts) and

substance abuse outcomes, in housing stability, in rate of employment, and in quality of

life; but no statistical significant difference was noticed between experimental sites and

control sites. More extensive implementation of systems integration strategies was also

unrelated to these outcomes. However, sites that became more integrated, regardless

of the degree of implementation or whether the sites were experimental or comparison

sites, experienced progressively better housing outcomes. It can be concluded from this

study that efforts to integrate systems lead to improvement at the systems organization

level, but they lead to little or no improvement in the clinical outcomes and quality of

life for severe mentally ill persons. One of the authors’ assumptions to explain these

results is that the presence of effective ACT services at experimental as well as control

sites, might be responsible for the overall positive effects, and that ACT services create

service integration from the bottom up 148 .

Rothbard et al. (2004) 149 studied the long-term follow-up data of the ACCESS program.

They compared for a limited number of participants (N=146) from one state the

Medicaid administrative data one year before, during and one year after termination of

the ACCESS study. In this study, no difference was made between experimental or

control site, since the results of the ACCESS study showed no difference in outcome

(Rosenheck 2002) 150 . It learned that one year after the ACCESS study, participants still

had a significantly larger use of ambulatory care and a better continuity of care

(outpatient contact within 30 days of inpatient discharge) as compared to the one-year

period before their participation. The percentage of homeless persons with SMI in need

of inpatient care or using emergency services was not different before, during and after

the ACCESS program. Although there was no difference in the percentage of SMI

persons in need of hospitalization pre-, during and post-intervention, hospitalizations

became shorter during the interventions and tended to stay shorter afterwards but the

difference was not statistically significant anymore. These results should be interpreted

cautiously, since there is a potential selection bias (continuously Medicaid eligibility for 3

years; or less than 25% of ACCESS participants for that state).

In a further evaluation of the first 2 year data of the ACCESS study, Rosenheck et al

(2001) 151 found a significant relationship between the social environment in the

community and the degree of service system integration as measured in the ACCESS

program. The community social environment was measured 1. by its “social capital”

(defined by the results of the annual national lifestyle and social behavior survey, and by

the % of people taking part in voting) and 2. by data on housing affordability. The higher

the “social capital” of a community, the higher the level of service integration in the

ACCESS study, and the higher the chance of exiting from homelessness for the ACCESS

participants. This chance was also influenced by the housing affordability. Thus,

according to these results the level of service systems integration seems to be

influenced by the social context in a community, and this remains important even when

additional efforts to implement integration strategies are provided.


56 Evidence Based Mental Health Services KCE reports 144

The results from the ACCESS study confirm the results from a previous large USA

study, the Robert Wood Johnson Foundation’s program on Chronic Mental Illness

(Lehman 1994) 144 (see before).

The previously mentioned RCT by McHugo et al (2004) 72 , including 125 participants,

confirm the results of the ACCESS study.

4.5.2.3 Care networks and service use

One Dutch study evaluated the effect of care networks on service use (Wierdsma

2007) 152 . Community care networks, consisting of a partnership between police force,

housing corporations, social services, specialized home care and mental health services,

were set up for chronic psychiatric patients in a few underprivileged neighbourhoods in

Rotterdam but not in other neighbourhoods with comparable social profile. Over a 10year

period, contacts with psychiatric emergency services were higher in the

neighbourhoods where community-care networks were set up, and number of

admissions and standardised ratios for involuntary admissions were lower. The

community-care networks had a significant impact on the use of mental healthcare

services. The study did not describe individual patient outcomes.

4.5.2.4 Shared care

In this paragraph interventions in line with the definition of Shared care (see chapter

4.1.1.4) will be discussed. Only reviews or studies including SMI persons have been

retained.

As will be noticed, some authors prefer the term “collaborative care” instead of

“shared care” when discussing liaison services (e.g. Craven et al (2006) and Mitchell et al

(2002) 43, 44 ).

Finally, 2 studies will be presented that don’t deal with “Shared care” as defined in

4.1.1.4, but in these publications a shared or joined patient-doctor decision making is one

of the key elements of the intervention. The authors of the first study call this

“collaborative care” (Bauer et al (2006); Simon et al (2006) 45, 46, 153 ); the authors of the

second publication call it “shared decision making” or “integrated care” (Malm 2003) 47 .

A. Cochrane and CRD database

Cochrane Review by Smith et al (2007) 41 : “Effectiveness of shared care across the

interface between primary and specialty care in chronic disease management.”

This Cochrane review on chronic diseases includes studies based on the liaison model,

based on shared-care record cards or IT-supported shared care, or based on combined

interventions. Three studies on persons with chronic mental illness are included: Byng

2004 (RCT) 154 , Wood 1994 (controlled before-after study) 155 and Warner 2000

(RCT) 156 . Byng evaluated the liaison model (“Mental Health Link”) between primary care

mental health teams and GPs practices (335 participants). Wood evaluated the liaison

model between a specialist case management team and GPs practices (118 participants);

and Warner evaluated patient-held shared care record cards (90 participants). All three

studies had some methodological flaws. Byng in the UK reported a significant 32%

difference in number of patients experiencing a relapse; Wood in New-Zealand found a

significant decrease in number of patients that were re-admitted, and in the number of

in-patient days. Warner in the UK found no difference in general mental health

outcome. Quality of life and satisfaction with treatment were not different in Byng or

Warner. The authors of the Cochrane review conclude that there is insufficient

evidence to demonstrate overall significant benefits from shared care.

Cochrane Review by Gruen et al (2003) 157 : “Specialist outreach clinics in primary care

and rural hospital settings”.

This Cochrane review included one study reporting separately on SMI persons

(psychosis): Williams 1989. It shows that, for the time period 1973-1981 as compared

to before, the development in the UK of psychiatrist liaison services to general practices

was accompanied by a nationwide reduction in admissions of non-psychotic disorders;

however this was not true for psychotic disorders.


KCE Reports 144 Evidence Based Mental Health Services 57

However, this type of observational studies does not necessarily imply a causal

relationship, since many other factors might have contributed to the effect on patient

admission.

Roberts L et al (2001) 158 : Systematic Review: “The effectiveness of health assessments in

primary care as a strategy for improving both physical and mental health in patients with

schizophrenic illness”. West Midlands Health Technology Assessment Collaboration,

Department of Public Health and Epidemiology, University of Birmingham (WMHTAC).

The available data are insufficient to determine the effectiveness of health assessment

for schizophrenic patients in primary care. There is little evidence to suggest that

undertaking health assessment of schizophrenic patients (outside of the usual health

promotion activity of general practice) in primary care is an effective way of improving

the mental or physical health of this patient group.

B. Medline, PsycInfo, Embase

Craven et al (2006) 43 : Systematic review: “Better practices in collaborative mental health

care.”

In this systematic review of low quality the term “collaborative care” largely

corresponds to the definition of “shared care” used in this report. The review by

Craven et al is also mentioned in McDonald et al (2007) 159 . Craven et al include 7

studies on persons with SMI: Warner 2000 (RCT, also included in the Cochrane review

on shared care) 156 , Lester 2003 (RCT) 160 , Burns 1998 (RCT) 161 , Gater 1997 (RCT) 162 ,

Bindman 2001 (case-control) 163 , Cook 2003 (before-after design) 164 , Druss 2001

(RCT) 165 . Six studies were UK-based, one study USA-based (Druss 2001). The authors

of the review assigned to each study a “level of collaborative care”, which could be high,

medium or low. The rationale of this rating was not explained.

Warner 2000 and Lester 2003 (203 patients) both report on patient-held clinical care

records carried back and forth between providers. From these 2 studies it is concluded

that this may have some positive effects on communication but that changes in clinical

outcomes are unlikely.

A liaison model of service provision is evaluated in the studies of Gater 1997 (89

patients), Druss 2001 (120 patients) and Bindman 2001; in the Gater study each patient

additionally has a care coordinator. Gater and Druss reported more guidelineconsistent

care, more patients had regular contacts with services and patients were

more satisfied with care. Bindman found that admission rates to specialist care are not

enhanced by the intervention.

The study of Burns 1998 examines the impact of teaching UK nurses to carry out

structured patient assessments; but this study is excluded by Craven et al because of

major flaws. The study of Cook 2003 has a mixed intervention (liaison, patient held

record, ACT, accommodation and therapy supply, staff training), so that it is difficult to

disentangle the element responsible for the results.

From this review it is clear that more studies in the field of SMI persons are necessary

before firm conclusions can be drawn on the role of shared care.

Mitchell et al (2002) 44 : “Does primary medical practitioner involvement with a specialist

team improve patient outcomes: a systematic review”.

This SR of good quality includes 2 trials on persons with SMI: Wood et al (1995) 155 (also

included in the Cochrane review by Smith et al (2007)) and Gater et al (1997) 162 (also

included in the review by Craven et al (2006)) (see before).

The formal liaison between GPs and specialist services in outpatient care seems to have

modest beneficial effects in chronically mentally ill patients, but results are only based on

2 controlled trials of 118 and 89 patients respectively.


58 Evidence Based Mental Health Services KCE reports 144

Fitzpatrick et al (2004) 166

This prospective observational study describes data from 349 SMI persons from 50 GP

practices in London who were followed during one year. Level of shared care (SC) was

scored by the GP on the SCAS (Shared care assessment schedule); low, medium and

high level of SC was defined on the tertiles of all patient scores. High SC represents

active involvement of primary and secondary services with good communication, low

SC represents patient management almost entirely by general practitioner (GP) or

within secondary care. At 12 months, there was no difference between participants

receiving different levels of shared care for number of hospital admissions or length of

stay. Also, there was no difference between participants receiving different levels of

shared care for change in global clinical symptoms, social functioning or satisfaction with

services. The authors conclude that high shared care had limited value for patients in

terms of improved clinical, social or general health functioning over 1 year. However,

there may be other drivers for implementation of shared care, e.g. managing risk or

supporting professionals.

Kisely et al (2006) 167 conducted in Canada a survey among 37 primary care physicians

with access to mental health workers, e.g. psychiatrists, psychologists, social workers,

nurses, who provided on-site clinics in mental health care. They were compared to 64

primary care physicians without such access. The methodology of this survey-based

study is weak, but the results are mentioned because of the qualitative information.

Results should be treated cautiously. The first group reported significantly better

knowledge in some areas of diagnosis and therapy of mental health problems (e.g.

psychosis). They also reported more comfort in managing these problems, and were

more satisfied with mental health services, over and above shared care.

Shared or joined patient-doctor decision making as a key element of the intervention

Two studies (Bauer 2006, Malm 3003) don’t deal with “Shared care” as defined in

4.1.1.4, but a shared or joined patient-doctor decision making is one of the key elements of

the intervention. As discussed below, the interventions in these studies are complex

and multi-faceted, so it is difficult to conclude on the precise role of the “joined

decision-making” in the results.

Bauer et al (2006) 45, 46 and Simon et al (2006) 153 evaluate a model that they describe as

the “Collaborative care model”. It includes 1. joint (patient-doctor) problem definition,

goal-setting and planning 2. group psycho-education (4-6 persons) on self-management

skills (Life Goals Program) 3. simplified practice guidelines to support clinician decision

4. nurse care coordinators. The model is evaluated for severely ill patients, in a multicenter

RCT and involving 330 patients with bipolar disorder and many co-morbidities

(Bauer 2006), respectively 441 patients with bipolar disorder but less co-morbidities

(Simon 2006). At three (Bauer) respectively two (Simon) years, the frequency and

severity of mania in bipolar disorder was significantly reduced by the systematic careprogram.

The effect on the depressive episodes was less clear. There was no difference

in psychiatric hospitalization rate or medication use between groups. The effect on

social functioning and QoL was not clear.

Malm et al (2003) 47 conducted an RCT and included 84 SMI persons with schizophrenia.

SMI persons involved in shared decision making carried out in social network resource

groups, including training in problem solving and communication, do significantly better

at 2 years follow-up for social functioning and satisfaction with treatment, but not for

clinical functioning.


KCE Reports 144 Evidence Based Mental Health Services 59

4.5.2.5 Systems and services integration: conclusion

Does systems integration affect continuity of mental health care and patient outcomes?

The RWJ study and the ACCESS study learn that efforts to integrate systems lead to

some improvement at the system’s organization level. Their effect on continuity of

mental health care for SMI persons is not clear and at best limited. However, they lead

to little or no improvement in the clinical outcomes and quality of life for severe

mentally ill persons.

Many methodological limitations can be formulated in relation with these studies. On

the other hand, it is probably difficult to improve study quality for this type of very large

and complex interventions.

To the most fundamental criticisms belong the following:

• in the RWJF study as well as the ACCESS study selection bias cannot be

excluded (see above), which further compromises the study outcomes;

• study duration was not long enough to capture real changes, especially at a

systems level (although the follow-up duration for the ACCESS study was

four years);

• indicators of continuity of care were too narrow and some important aspects

were not captured; after these studies some more sophisticated instruments

to measure CC became available (e.g. the ACSS-MH or Alberta continuity of

service scale for mental health)

• evaluation of patient outcomes, especially patient satisfaction with services,

was too limited to capture changes;

• the relationship between service systems integration, continuity of care at a

patient level, and patient outcomes is very complex and is determined by

many other factors. This makes it very difficult to measure a direct

relationship between patient outcomes and service systems integration or

continuity of care.

Shared care as defined in this report can be considered to be a specific subtype of

systems and services integration. It addresses specifically the boundary between primary

care and specialist care. It has most been studied as the liaison model: in a meeting

between specialists and primary care professionals clinical problems are discussed, and

often this is supplemented by a clinic run by specialists in a primary care setting. Results

so far are not consistent in terms of improved clinical, social or general health

functioning of the patient, or patient satisfaction with care. However, there may be

other drivers for implementation of shared care, e.g. managing risk behavior by patients

or supporting professionals. Another form of shared care is the use of shared care

record cards to facilitate communication between professionals; these cards are usually

carried by the patient. There is no evidence that it improves mental health status of SMI

persons or their satisfaction with care; especially patients with psychotic illnesses are

less likely to use the cards.

Given the enormous efforts (man-power as well as subsidies and funding) that are

necessary to implement systems integration for (severely) mentally ill persons, and given

the limited evidence that this improves patient outcomes, caution is warranted not to

overstate the importance of systems integration and services continuity of care. One

should not forget that many other aspects, among which the intrinsic quality of the

provided services, are at least as important: “ineffective services are not improved by

better integration” (Goldman 1994) 58


60 Evidence Based Mental Health Services KCE reports 144

4.5.3 Care programs, Care pathways

A. Cochrane and CRD database

No references retrieved

B. Medline, PsycInfo, Embase

“Care programs” and “Care pathways” in mental health care clearly belong to the focus

of the main questions for this report formulated by the Belgian Government. A specific

search (summer 2007; repeated in June Nov 2009 because of the importance for the

report) followed by selection through the main in- and exclusion criteria, did not yield

results for “Care programs”. For “Care pathways” in mental health care, Evans-Lacko et

al (2008) 63 provide an overview of all research published so far. Eight studies were

included, six of these concerning SMI persons. However, several studies did not specify

clear outcome criteria. One study included a control group but conclusions from this

study are difficult to make because of a low completion rate. Overall, the study results

were mixed and due to the low overall quality, no conclusions can be made.

Importantly, most of the studies cited the importance of contextual factors in the

development of the care pathways.


KCE Reports 144 Evidence Based Mental Health Services 61

5 LITERATURE REVIEW: CONCLUSIONS

5.1 DIAGNOSIS OF “CHRONIC AND COMPLEX” OR “SEVERE

AND PERSISTENT” MENTAL ILLNESS.

In 2005, the federal Minister of social affairs and public health commissioned the

“Therapeutic Projects”, meant to try out new initiatives to create care circuits and care

networks for “persons with a chronic and complex mental disorder”. The present

report can be seen in the broader perspective of a reflection on the organization of

care for this patient group. Indeed, in Belgium a specific subgroup of mentally

disordered persons is considered to be suffering from a chronic and complex disorder,

and this term is widely used although no specific scientific definition exists. More

precisely, “chronic” relates to duration and persistence of the disorder. “Complex”

rather refers to the fact that these persons have needs that cannot easily be solved by

one single professional discipline because many dimensions, including functioning in daily

life and participation to society, are involved. .

In the contemporary scientific literature, most authors prefer the expression

“persistent” to the word “chronic”, which is felt to have a negative connotation; and the

complexity of the included disorders is expressed by “severe”. Since the principal aim of

this study is to give an overview of existing scientific evidence, the term “severe and

persistent” mental illness has been used, rather than the term “chronic and complex”.

5.1.1 Definition of “severe and persistent” mental disorders

According to the scientific literature, the definition of “severe and persistent” mentally

ill patients (SMI patients) includes 3 components: diagnosis, duration of illness, and

severity of illness (or degree of functional impairment) along the spectrum of a certain

diagnosis (see chapter 2).

Although for all included publications in the literature review of this study the 3

components (diagnosis, duration and severity) were looked for, in the majority of

papers only the diagnosis was mentioned.

To make it even more complicated, diagnostic categories varied from one to another

paper. Two diagnoses were often but not always included when considering “chronic”

or “severe and persistent” mental illness. The most important is schizophrenia and

other forms of non-organic psychosis, usually accounting for more than half of the

described patient population, and sometimes the only included diagnostic category. The

second most important diagnosis is major affective disorder, i.e. bipolar disorder and

sometimes also major depression. It is confirmed in the literature that these two

diagnostic categories are the 2 most important SMI diagnoses (Bhugra 2006) 168 .

Personality disorders, often without any specification, are sometimes also taken into

consideration but they usually account only for a small subgroup of all included study

participants; some papers deal with this diagnosis separately. Substance abuse and

addiction are mostly only included in SMI studies when they are secondary to another

“chronic” or “severe and persistent” disorder; as primary diagnosis they are usually

excluded. The problem of offenders and forensic psychiatry, is mostly considered as a

specific subcategory of “severe and persistent” psychiatric care and is dealt with in

separate papers.

Adding to the problem of which diagnostic categories to include, is the well-known fact

of the cultural influence on psychiatric diagnoses (Bhugra 2006) 168 . For instance,

Jablensky et at (1992) 169 showed that the rates of narrow definition schizophrenia were

broadly similar across nations, but broader definition schizophrenia varied nearly

twofold.

A further problem is that in those papers including “duration” in the diagnostic criteria

of SMI, different cut-offs are used, varying from 6 months to 2, 3 or even 5 years (see

KCE-report n° 84). When the criterion of severity is included, different outcome scales

are used to measure it, making comparability from one study to another difficult.


62 Evidence Based Mental Health Services KCE reports 144

In conclusion, the necessity of 3 components for the scientific definition of SMI so far

still remains largely theoretical. In the majority of the published scientific papers

inclusion criteria for the group of severe and persistent mentally disordered patients are

limited to the medical diagnosis and the duration of the disorder. So far the available

scientific evidence as to the disability-concept remains limited. No uniform operational

definition yet exists for “severe and persistent mental illness”, and variation is possible

from one study to another.

Notwithstanding its vagueness due to the lack of well-defined in- and

exclusion criteria, the concept of SMI is generally accepted and often used in

the literature. The Cochrane reviews, to give only one example, solve the problem by

using as an inclusion criterion “severe and/or persistent, however diagnosed”.

In the Belgian context of care organization for this group of patients, the concept of

“chronic and complex” or “severe and persistent” is in practice often defined based on

the patient’s diagnosis combined with a minimal duration of six months of illness.

However, if one aims at developing a framework for organization of (chronic) care for

these persons, it should be repeated once more that the WHO and other influential

institutions state that the actual needs of the persons suffering from SMI should be the

starting point for every therapeutic and social care-giving act. Notwithstanding the fact

that in practice most of the patients of the SMI group will belong to only a few

diagnostic categories, their needs might be different depending on their living situation: a

chronic schizophrenic person living in an institution has different needs compared to the

same person living independently in society.

5.1.2 Prevalence of severe and persistent mental disorders

It was not the purpose of this report to give an exhaustive overview of the literature on

prevalence of severe and persistent mental disorders. Nevertheless it seems useful to

give a global impression of the number of affected persons, starting from the 3 most

frequently included diagnoses (see 5.1.1)

According to recent overviews, schizophrenia has a life-time prevalence (proportion of

individuals alive on a given day who have ever manifested a disorder) of 0,4% and an

annual prevalence of about 0.3% (proportion of individuals who manifest the disorder

during a time period of 1 year) (Saha 2005) 170 . For bipolar disorder (Ketter 2010, Ormel

2008) 171, 172 , the life-time prevalence is 4% and the annual prevalence 1,4%. For major

depressive disorder, the life-time prevalence varies from 6-18% and the annual

prevalence from 4-6% (Patten 2008) 173 . However, as discussed by Patten, a certain

proportion of major depressive disorders will recur, but not every person suffering a

major depressive disorder will finally respond to the diagnostic criteria for SMI. In the

WHO survey ESEMeD (2001-2002), the annual prevalence of “serious mental

disorders” in Belgium was 4,9%. “Serious mental disorders” were defined as severe and

persistent mental disorders (SMI persons) plus either a 12-month suicide attempt, an

impulse control disorder with repeated serious violence, or any other mental disorder

that resulted in 30 or more days in which the respondent could not carry out daily

activities as usual (Bruffaerts 2009) 174 .

In conclusion, severe and persistent mental disorders are not rare, and an annual

prevalence lower limit of about 1% seems a realistic estimation.


KCE Reports 144 Evidence Based Mental Health Services 63

5.2 LITERATURE EVIDENCE ON ORGANIZATION OF

MENTAL HEALTH CARE

5.2.1 Methodological reflections

It is difficult to evaluate interventions aimed at producing change in the organisation and

delivery of health care services, because they are usually very complex. Complex

interventions are defined by the UK Medical Research Council as those comprising ‘‘a

number of separate elements which seem essential to the proper functioning of the

interventions although the ‘active ingredient’ of the intervention that is effective is

difficult to specify”. (Shepperd 2009) 175 . Typical examples of such complex interventions

are case management, interventions to improve continuity of care etc.

Shepperd et al (2009) 175 underline the methodological issues arising from the synthesis

of data from complex interventions. Important difficulties, and possible solutions

proposed by these authors, are:

(1) defining the intervention within the review; solutions can be using a typology for

classification; contacting authors for precise information on interventions, using

supplementary evidence e.g. including a broader range of study designs or qualitative

data to describe the active ingredients of the intervention;

(2) searching for and locating (all) relevant evidence; solutions can be performing an

iterative scoping exercise, retrieving references of references, searching outside

traditional health care domains;

(3) standardizing the selection of studies for a review; solutions can be refining the

definition of the intervention of interest through an iterative process when assessing

how similar another intervention is; being explicit in the review on difficulties in

classifying certain studies;

(4) synthesizing data; a solution can be synthesizing heterogeneous data by means of a

narrative review, paying attention to intervention content (specifying active ingredients

and contextual similarities/differences between trials), to intervention fidelity and

sustainability (did the intervention fail because it was poorly implemented), and to the

applicability of the evidence in other health systems.

The subject of the literature review in this report typically belongs to the domain of the

“complex interventions”, and indeed, many methodological difficulties might hamper the

results.

(1) To standardize as much as possible the “intervention” in this review, the

organization of mental health care, and to stratify the diversity of mental health services,

a “typology” has been used: the ESMS. This taxonomy for classification of mental health

services has a glossary describing its subdivisions and has been validated for use in

several countries; and although not perfect, it was judged to be the most relevant given

the scope of this study (see chapter 2).

A rather broad selection of study designs has been included (meta-analyses, (systematic)

reviews, RCTs and clinical trials, cohort studies, case-control studies). Whereas this

strategy certainly widened the variety of organizational concepts that have been

included, results should be interpreted with caution. On the other hand, qualitative data

has only been picked up when retrieved through the general search strategy and no

specific search on qualitative data has been performed. For pragmatic reasons, the

search in this report has been limited to non-sociological databases.

(2), (3) To address the lack of consistent terminology and the inconsistent use of

existing terminology to describe mental health care organizational interventions, the

ESMS has guided the literature search strategy (see Appendix to chapter 3). On the

other hand, the scope of this taxonomy is to give an inventory of mental health services,

and not of the content of the delivered interventions delivered, nor of the combination

of certain types of interventions.


64 Evidence Based Mental Health Services KCE reports 144

However, to validate the search outcome and to include the most important subjects

that might have been omitted in the first search, an independent researcher conducted

a second search (see Appendix to chapter 3). These search results were matched with

the first search strategy.

In this review, a broad search strategy has been used (see Appendix to chapter 3), and

iterative exercises and scrutinizing of reference lists have been performed. However,

due to the inconsistent use of existing terminology it is possible that potentially eligible

studies have not been identified or have been discarded early in the review process.

Moreover, on many service components belonging to the arsenal of most West

European countries, e.g. day centres for SMI persons, no publications were found; so it

is not possible to conclude on their efficacy as compared to other services.

(4) As can be concluded from the evidence tables in the Appendix to chapter 4, the

heterogeneity between the included studies is large, not only for the included SMI

population (e.g. only psychoses or not) but also for the evaluated outcome domains

(clinical symptoms, quality of life...) and the outcome scales used. Throughout the

literature, a similar term is used for services that not necessarily provide the same, and

the comparator “usual care” is often ill defined. Moreover, as already pointed out in

chapter 2, due to their social characteristics service interventions are never alike; and

an intervention never gets implemented identically because of differences in context,

timing, processes, stakeholders etc. Many of the studies included in this literature

review were conducted in the USA or UK, and caution is warranted when transferring

the results to the Belgian context.

Taking all these methodological limitations in consideration, and taking into

account the potentially important influence of contextual factors, the

retrieved evidence mostly was of low or at very best of moderate quality

(Gyatt).

However, given the complexity of organizational interventions, it is not

unlikely that even the best review will always leave much more uncertainty

than for instance reviews dealing with the efficacy of drugs. Organizational

interventions are always inevitably contextually embedded; hence the notion

of intervention cannot automatically be considered as a standardized set of

elements.

5.2.2 Which mental health care services to organize for SMI persons?

Western Europe has witnessed a now well-established trend of deinstitutionalization for

persons with SMI, and a tendency towards community-based services. This

deinstitutionalization was started as a social movement characterized by the choice to

overcome stigma and integrate people with mental disorders into society, without

evidence being available for its feasibility or effectiveness. Since then, no persuasive

arguments came available to support a hospital-only approach. Evidence exists that

community care, including home-based care, is an acceptable way of treating people

with SMI, and is associated with more service satisfaction and quality of life (see chapter

4). Likewise, there is no scientific evidence that community services alone can provide

satisfactory comprehensive care. Instead, the weight of professional opinion and

results from available studies support “balanced care”, incorporating

elements of both hospital and community care. This concept has been first

described by Thornicroft et al.(Thornicroft 2004) 176 and also by Knapp et al (2007) 18 ,

and by Vieth et al (2009) 177 ; it implies that community-based and hospital-based services

commonly and in a coordinated way aim to provide treatment and care that are close

to home, including acute-hospital care and long-term residential facilities in the

community. Both community-based and hospital-based services should respond to

disabilities as well as to symptoms, they should be able to offer treatment and care

specific to the diagnosis and needs of each individual, they should be related to the

priorities of service users themselves and respect international conventions on human

rights.


KCE Reports 144 Evidence Based Mental Health Services 65

This “balanced care” model should be a “pragmatic” balance between

hospital care and community-based services, which means that no fixed

number of beds or community places can be put forward. These numbers

are highly dependent upon what other services exist locally and upon local

social and cultural characteristics (Thornicroft 2004) 176 .

The model is also presented as a “stepped care” model, which implies that, depending

on the needs of the patient, first level care should be offered first, and second or third

level only when necessary.

The first level of this model implies primary care with specialist back-up. The second or

mainstream specialist level consists of outpatient and ambulatory clinics, community

mental health teams, acute in-patient care, long-term community based residential care,

and services in charge of employment and occupation. The third level or highly

specialized (differentiated) mental health services are optional, but it is supposed that

high resource level countries such as Belgium, are able to offer some of them,

depending on the local context of service provision. A few examples are specialist

clinics e.g. for eating disorders, home treatment and crisis resolution teams, facilities for

independent living.

A few additional remarks pointing to specific domains in the large field of

mental health care organization, can complete the knowledge on which mental

health services to provide. It should be kept in mind that many of the included studies

were performed in the USA or the UK, so extrapolation toward other countries should

be done with caution.

• For homeless SMI persons, providing permanent housing and support can

significantly reduce homelessness, hospitalizations and imprisonment

(moderate quality of evidence). It does not influence clinical symptoms, social

outcome or quality of life as compared to standard treatment. Providing

“housing services” and “support services” in an integrated way is more

effective as compared to non-integrated service provision. Results are

comparable to the effect of ACT (see further) on housing stability; for this

group of SMI persons ACT has additional advantages on clinical symptoms.

• Home care crisis treatment, provided within other ongoing home care

services, is an acceptable way of treating SMI persons, with comparable

clinical outcomes and better acceptance by both patients and family as

compared to acute in-patient care (moderate quality of evidence). However,

it is estimated that about half of these patients are unable to avoid hospital

admission at a certain point during follow-up.

• For persons in acute distress (all diagnoses), acute day hospital treatment is a

valuable alternative to acute in-patient care, with comparable results for

clinical and social outcome, quality of life and satisfaction with treatment

(moderate quality of evidence). However, it is not a valid option for everyone

and it is estimated that it is feasible for 1/5 to 1/3 of those currently

admitted to inpatient care.

• There is insufficient evidence to determine whether day hospitals providing

day treatment programs (more intense treatment for patients who failed to

respond to outpatient care) or transitional day hospitals (time-limited care

for patients who have just been discharged from hospital) have advantages

over outpatient care for SMI persons.

• Community mental health teams are not inferior to hospital based care or

non-team outpatient care for SMI persons, and they are superior in

promoting greater acceptance of treatment. They probably reduce hospital

admission during follow-up, but further research is necessary (low quality of

evidence).


66 Evidence Based Mental Health Services KCE reports 144

• Home-based continuing treatment for mental disorders including SMI

persons, can reduce the number of days spent in hospital during follow-up,

when compared to hospital based care. The difference between home-based

care and other forms of outpatient care is less clear. Evidence for this

conclusion is of moderate quality. However, attention should be paid as to

the sustainability of these services since many of them have disappeared after

some years.

• It is not possible to decide on the efficacy of non-hospital-based day-centers

that offer structured activities for patients with long-term severe mental

disorders, since no studies based on good methodological principles were

retrieved.

• There is moderate quality of evidence that supported employment models,

which emphasize rapid placement in competitive jobs with “on-the-spot”

support and follow-up from professionals, are more effective than vocational

rehabilitation, and can increase rates of competitive employment.

• There is moderate quality of evidence that case management (a case manager

provides coordination for health and social care needs for SMI persons

residing in the community. He typically works more individually than ACT

managers who work in team, and has a higher case-load. He refers clients to

care providers rather than providing care necessary interventions by himself)

can ensure that more people remain in contact with psychiatric services (one

extra person remains in contact for every 15 people who receive case

management). However, it increases hospital admission rates (moderate

quality of evidence). Effects on clinical symptoms or the patient's level of

social functioning are not clear.

• ACT (assertive community treatment: a multidisciplinary team that

coordinates the care of SMI persons in the community, preferably at the

patient’s own home or work place. The team attempts to provide necessary

interventions by themselves rather than referring patients to other

providers): evidence exists that ACT can decrease hospitalization, decrease

the number of SMI persons lost to follow-up and increase the number of SMI

persons living independently, being employed and being satisfied with their

services. Effects on clinical outcomes or social functioning are less clear.

Some recent studies in a European context failed to find the same positive

outcomes on hospital use. It seems that the effect of ACT on the rate of

hospital admissions is most pronounced when hospital use is intense; in other

words, if hospital use is already low, ACT is not likely to reduce it further.

• For people with dual diagnosis (co-occurring mental disorder and substance

abuse), the existing evidence does not support integrated treatment of both

disorders, but further research is still necessary.

• Due to a lack of consistent publications, it is currently not possible yet to

judge whether specialized early intervention teams (e.g. early psychosis

teams) should be seen as a priority.


KCE Reports 144 Evidence Based Mental Health Services 67

5.2.3 Integrated care, Continuity of care, Care pathways and Networks of care

for SMI persons: the evidence.

5.2.3.1 The concepts “integrated care” and “continuity of care”

During the last few decades, the concepts “integrated care”, “service integration” and

“continuity of care” have been used broadly in the field of service organisation for

people with complex needs. Throughout the Western world, these concepts are also

widely considered to be important elements of contemporary care for mentally

disordered persons, especially for those with severe and persistent mental disorders.

This vision implicates the assumption that non-integrated, discontinuous service delivery

systems are less able to address the needs of these people.

The goals of integration are to provide comprehensive services; to improve access to

these services; to improve continuity of care; and to reduce service duplication,

inefficiency and costs (Randolph 1997) 48 . Ultimately, this should lead to an improved

clinical status and better quality of life for the person with mental illness (Durbin

2006) 49 .

So far, no uniformly accepted definition of “Integrated care” (IC) or “Continuity of

care” (CC) exists is in the literature on mental health care, but it is clear that they are

complex concepts with many different aspects (see chapter 4.1). It is beyond the scope

of this report, to give a comprehensive theoretical background on these concepts.

Rather a practical overview is given of the interpretations found while evaluating the

literature on mental health care organization; these descriptions have been used also

elsewhere in this report.

Integrated care

According to several authors (Randolph 1997, Durbin 2006) 48, 49 , when using the

concept of IC, its content should be clarified as to the following aspects:

A. The service system level toward which activities are directed. This can be the “patient

level” (for individual patients e.g. integration by case management), or the “service

systems” level (for a defined population as a whole, e.g. program integration, integration

at the state-level etc.).

B. The intensity of IC (a continuum ranging from loosely organised alliances to highly

integrated organizations); and the formality of IC governance (a continuum from informal

verbal agreements to formal procedures and rules).

In practice, the same authors often encounter the following five levels of increasing

integration: information sharing and communication, cooperation and coordination,

collaboration, consolidation, and full integration (see also 4.1.1.5).

To understand how IC and CC potentially can affect patient outcome, and how they

relate one to another, Durbin et al (2006) 49 developed the “Systems integration logic

model” (see Fig), a model describing 3 steps in this interaction process. Brief, a certain

care system has a certain level of system performance (including the use of certain

integration mechanisms), leading to the services outcomes (among which continuity of

care); these service outcomes potentially influence clinical symptoms and quality of life of

the patient. According to Durbin et al these steps are all influenced by the context of

the community: e.g. in a community context of a high level of unemployment, less

results can be expected from efforts to integrate vocational rehabilitation into the

general service supply for SMI. For more details, see 4.1.1.5.


68 Evidence Based Mental Health Services KCE reports 144

Fig: the Systems integration logic model (Durbin 2006) 49

Continuity of care

When discussing “Continuity of care” in mental health services, reviews usually go back

to the definition of Bachrach in 1981 50 , who defined CC as “the orderly uninterrupted

movement of clients among the diverse elements of the service delivery system”. In the

next phase, it becomes almost impossible to distinguish CC from interventions such as

case management or ACT, since these interventions were basically developed to

improve the continuity of care (Adair 2003) 52 .

A next landmark is the “state of the science” given by Johnson et al (1997) 53 , on

“continuity of care” for severely mentally ill persons. Johnson distinguishes the following

aspects of CC for SMI persons:

1. Cross-sectional:

• receipt of a comprehensive range of services in accordance with needs:

o continuity between service providers (degree of communication between

agencies and professionals involved in the patient’s care),

o comprehensiveness (the range of services provided to meet the patient’s

needs),

o accessibility of services (distance to facilities).

2. Longitudinal:

• sustained contact with services and providers over time:

o continuity of contact (provision of out-reaching care to stay in contact

with patients),

o continuity of service provider (patients receive services across time from

the same staff),

o implementation of service plans,

o continuity through discharges and transfers (flexible and rapid transfer

between care levels according to varying needs of patients).

To these aspects, Crawford et al (2004) 54 add still another important dimension:

patients’ views of the care they receive (“do they experience care as smooth and

uninterrupted”).


KCE Reports 144 Evidence Based Mental Health Services 69

Whereas in the literature on mental illness still other definitions on CC are sometimes

used by other authors, they usually come back to the factors mentioned above (see also

chapter 4.1).

Given the diversity of possible interpretations of the concept IC or CC, it is

of utmost importance to elucidate the concept whenever referring to it, and

to define which aspects are included. Not giving a clear description of which

aspects are aimed at, will almost certainly lead to confusion or misunderstanding, given

this complexity.

Care programs and Networks of care

Other concepts often used in the context of mental health care organization, are “Care

programs or care pathways” (CP) and “Networks of care”.

CP is defined in this report as a proposed sequence of steps for clinical care for a

particular group of patients.

A “network of care” can be defined as a collection of services which may vary in their

activities or organization, but which share a common mission, operate in a more or less

planned and collaborative manner, and participate in an overall coordinating or planning

body or authority to which each has a degree of accountability (Kates et al 1993) 59 . In a

theoretical background to networks, Goodwin (2004) 60 includes the dimensions

“pattern of ties or links” and “accountability”; Perry (2006) defines networks on 2

continuums (social regulation and social integration); each network can be characterized

by a certain degree of social regulation (hierarchy, accountability) and a certain degree

of social integration (strength of binds between individuals belonging to the

network)(Van den Holen 2008) 61 .

According to ANAES (2004) p , care networks aim to improve access to care, to improve

care coordination, and to facilitate inter-disciplinary care for a subgroup of patients,

disorders or services; care networks provide individually tailored care including

diagnosis and treatment as well as prevention and patient education. Besides quality

improvement, cost-effectiveness has also been mentioned as a potential advantage of

care networks (Van den Holen 2008) 61 .

In Belgium, the French term “trajets de soins” and the Dutch “zorgpaden” are the

proposed translations for “care pathways”. Nevertheless, it is interesting to note that

among experts that collaborated on this report, the impression exists that the actual

content of this term is differently interpreted in the French and the Dutch part of the

country. This again emphasizes the need to clarify these concepts whenever they are

used in a clinical and/or an organizational context, to avoid misunderstandings.

5.2.3.2 The literature evidence on “integrated care”, “continuity of care”, “care

networks” and “care pathways” for SMI persons

Integrated care and continuity of care at the patient level

p www.anaes.fr

Some types of community care described above, actually include care integration and

care coordination on the patient level: case management, ACT, integrated care for dual

diagnoses (see 5.2.2)

Integrated care and continuity of care at the systems level

When evaluating the scientific literature on IC and CC for SMI persons, few but

nevertheless important publications were found, all using different definitions and/or

measures for “Service integration” or CC, which makes direct comparison difficult.

Nevertheless, they all pointed in the same direction:

Due to the many methodological difficulties discussed before, the quality of the

evidence is low. On the other hand, it is probably difficult to improve study quality for

this type of very large and complex interventions.


70 Evidence Based Mental Health Services KCE reports 144

-Efforts to integrate systems lead to improvement at the systems organization level, but

they do not clearly affect continuity of care at a patient level, and they lead to little or

no improvement in the clinical outcomes and quality of life for severe mentally ill

persons. An exception is improved housing stability for homeless persons with SMI, if

housing services are integrated in the global service package for these people.

-Likewise, measures of CC can be useful in evaluating changes in the process of care,

but CC is not straightforwardly related to individual outcome. So far, it has not been

proven that CC by itself or in interaction with other features of service delivery

ultimately improves well-being of SMI persons as defined by symptom control,

functioning or quality of life.

One specific subtype of systems or services integration is Shared care, addressing the

boundary between primary and specialist care. Best known is the liaison model of care,

for which results in terms of improved clinical, social or general health functioning are

so far inconsistent, as well as outcomes in the domain of patient satisfaction with care.

The scientific literature search yielded one more publication specifically addressing Care

networks for SMI persons; no patient outcomes were mentioned and more evidence is

necessary before firm conclusions can be made. For Care pathways, one review was

found in which no conclusions could be made on the merits of this concept due to the

scarce and inhomogeneous research available. In the 2 nd part of this report

(“International overview”) some additional information on Care networks will be given

In conclusion, given the limited evidence that IC and CC at the systems level

improve outcomes of SMI persons, and given the enormous efforts (manpower

as well as financials) that are necessary to implement it, caution is

warranted not to overstate the importance of IC and CC. Many other

aspects, among which the intrinsic quality of the provided services, are at

least as important: “ineffective services are not improved by better

integration” (Goldman 1994) 58 .

5.3 LIMITATIONS OF THE LITERATURE REVIEW

The methodological limitations typical of an EBM literature review and typical of

complex interventions have already been discussed before (see 2.4 and 5.1). Some other

limitations should also be considered.

Search strategy

- a broad search strategy with a minimum of specific terms has been deliberately used.

Notwithstanding these efforts, it is not unlikely that publications have been missed,

which is almost inevitable given the wide scope of this report.

Inclusion criteria

-considerable sociological research exists on the general theme of inter-organizational

relations and networks of services, which has not been included in this report.

-in line with the international definitions, primary addiction problems were not

considered to belong to the group of SMI persons. However, this implies already a bias

and it prohibits looking objectively to the existing organizational structures in which

often addiction problems are considered to be a separate group. The same holds true

for forensic psychiatry and issues involving jurisdiction, as well as for psychiatric

disorders in persons with intellectual disabilities.

-the theme of stigmatization has not been included, although a broad set of outcome

parameters have been systematically looked for, such as medical and functional

outcomes, aspects of daily living, quality of life or satisfaction with services, burden of

carers. Stigmatization is an important theme though, and not only from the point of

view of the person himself. Stigmatization potentially affects choices made by SMI

persons which are reflected in organizational aspects.

-interventions aiming at family involvement were excluded, since they were considered

to be a certain type of “face-to-face treatment”. Nevertheless, such interventions

require specific organizational concepts, which would have been worthwhile mentioning.


KCE Reports 144 Evidence Based Mental Health Services 71

Research context

-as already emphasized at several points in the overview of the literature results, a lot of

research in this domain has been conducted in the USA and the UK. The basic

organizational and financing structures of mental health care and welfare in these

countries are quite different as compared to Belgium. One should be very careful before

introducing exactly the same concepts in our country; and when it comes to

implementation an in-depth evaluation of the organizational and financing context of the

concept should be made to avoid problems.

Research topics

-the empirical research that has been included was mainly based on experimental

research designs while there appears to be a lack of research using naturalistic designs

or focusing on real-life effectiveness. This remains a limitation of this report.

-mental health services research focusing on effects of social structure and

organizational culture or on inter-organizational relations and networks has been poorly

developed.

-especially the research on welfare services for SMI persons or on (non-hospital)

alternative accommodation modalities is poorly developed, although these are very

important themes given the de-institutionalization movement.

-evidence can also be generated by experiments “on-the-field”, such as the Belgian

“Therapeutic projects” and the “Therapeutic experiments”. The interested reader is

referred to the KCE-reports 103 and 123, which deal with this subject.

-it is obvious that if well-conducted research for a certain type of care provision is

absent, one should not conclude that it is not evidence–based. It is very well possible

that such a type of care provision has a valuable contribution to the mental health care

supply - it only awaits a careful evaluation.


72 Evidence Based Mental Health Services KCE reports 144

6 INTRODUCTION INTERNATIONAL

OVERVIEW

6.1 SCOPE OF THIS SECTION

This section describes the organisation of mental health care in a selected sample of

countries. It is descriptive and explorative, and does not aim to develop evidence on

“one best way” to organise mental health care, as health service delivery models are

profoundly affected by local conditions, historical developments and sociological,

political and economic characteristics of a country.

This global international overview aims at synthesising the general rationales for

organising mental health care services in other countries. The descriptive comparison

enables to deduct some common and diverging developments that could offer relevant

background knowledge to organise mental services, in this particular case in Belgium.

6.2 SELECTION OF THE COUNTRIES

We selected a sample of countries with a different history in health care organization,

(mental) health care reforms, as well as diverging welfare regime backgrounds. The

selection was based on a scan of available literature, contacts with key persons knowing

the reforms in the sector, a meeting with Belgian experts, and the advise of an

international expert.

1. Spain was chosen as an example of a geographically large southern European

country. Since the mid 1980’s it evolves as a Beveridge type model of health care

organisation. It is characterised by regional health care governance, with its

particular problems of regional divergences in the deployment of (mental) health

care services.

2. France has a Bismarck type of health care organisation and is chosen for its long

tradition of more hospital oriented care. Historically it was decided to have a

hospital in each department. The mental health care policy has been

characterized for its “sectorization” from 1975, in which the notion of catchment

areas was considered as an important starting point. The issue of collaboration

between the “cure” (medical) and “care” (social welfare) sectors for mental

health care organisation is at stake.

3. The most recent policy changes in health care organisation in the Netherlands

aim at developing a more demand/need oriented model allowing for personal

choices in the selection of services. The Netherlands have a history of

implementing community based mental health services, with a particular focus on

developing networks of care.

4. Denmark is characterised by a long tradition and focus on decentralised

community health care provision. The country has been subject to rather

fundamental reforms mainly dealing with the relation between country, region,

county and local communities. It has a quite particular approach in handling the

collaboration of medical and non-medical aspects of mental health care

5. The UK has a Beveridge type of national health insurance system, going through

movements of “market oriented” changes. It is characterised by decentralization

of political health care responsibilities to each of the “countries”. We mainly

focused on developments in England. Recently “trusts” got the responsibility to

provide in health services. England is chosen for its policy of gradually closing

large asylums, and its efforts to develop integrated community care. It was also

chosen because of its experience with scientific follow-up of mental health

reforms (e.g. the TAPS project doing a follow up of patients after closing down

mental hospitals)


KCE Reports 144 Evidence Based Mental Health Services 73

6. Australia was chosen for its internationally recognized efforts to reform in a

systematic way the mental health cure and care system and to introduce

innovative practices.

To make a comparison easier, we will start with a description of Belgium along the

same descriptive scheme.

6.3 GENERAL METHODOLOGY

In a first step, peer reviewed publications were searched in Medline, PsycInfo, Embase.

However, due to the scarcity of relevant information on organizational models in this

type of literature, this part of the report often relies on a grey literature search for

public information from administrative authorities, non-indexed reports from scientific

organizations, etc. Informal and personal communications with contact persons

(research institutes, administrators) from the countries studied also contributed to this

part of the report.


74 Evidence Based Mental Health Services KCE reports 144

7 BELGIUM

7.1 LITERATURE SEARCH: METHODOLOGY

For this chapter, a grey literature search was performed, including a web search on the

following websites: the FNAMS (Fédération Nationale des Associations Médicosociales)

q ; the RIZIV/INAMI (National Institute for Health and Disability Insurance or

NIHDI) r ; the Federal Public Service Health, Food Chain Safety and Environment s ; the

European Observatory on Health Systems and Policies t ; the WHO Department of

mental healthand substance abuse u Overlegplatforms Geestelijke Gezondheid van

Vlaanderen en Brussel, Plate-formes de concertation en santé mentale des Provinces

Wallons, Psychiatrieverband der Deutschsprachigen Gemeinschaft Belgiens v ; Juriwel (de

Vlaamse welzijns-, gezondheids- en gezinsregelgeving )w ; Wallex (Base de données

juridiques de la Région wallonne) x ; Vlaams Agentschap Zorg & Gezondheid y ; la Région

wallonne et la Commission communautaire française de la Région de Bruxellescapitale

z ; l’Institut Wallon de Santé Mentale aa ; LUCAS Centrum voor zorgonderzoek &

consultancy bb .

No information (references, data…) has been included after December 31, 2009.

7.2 GENERAL ORGANIZATION OF THE BELGIAN HEALTH

CARE SECTOR

The Belgian health system is mainly organized on two levels, i.e. federal and regional.

Since 1980, part of the responsibility for health care policy has been devolved from the

federal Government to the regional governments. Responsibility for health care policy is

shared between the federal Government, exercised by the Federal public service health,

food chain safety and environment, the Federal public service social security, the

National institute for health and disability insurance, and the Dutch-, French- and

German-speaking community Ministries of health (Corens D. Health system review:

Belgium) cc . The federal Government is responsible for the regulating and financing of the

compulsory health insurance; determining accreditation criteria for hospitals; financing

hospitals and so-called heavy medical care units; legislation covering different

professional qualifications; and registration of pharmaceuticals and their price control.

The regional governments are responsible for health promotion; maternity and child

health services; different aspects of elderly care; the implementation of hospital

accreditation standards; and the financing of hospital investment. Besides this, the

regional governments are also responsible for most aspects of chronic care, housing etc.

The Belgian health system is based on the principles of equal access and freedom of

choice, with a Bismarckian-type of compulsory national health insurance, which covers

the whole population and has a very broad benefits package. Compulsory health

insurance is combined with a private system of health care delivery, based on

independent medical practice, free choice of service provider and predominantly feefor-service

payment to the service provider.

q http://www.fnams.be/

r http://www.riziv.fgov.be/homenl.htm

s https://portal.health.fgov.be/portal/page?_pageid=56,512879&_dad=portal&_schema=PORTAL

t http://www.euro.who.int/observatory;

u http://www.who.int/mental_health/en/

v http://www.overlegplatformsggz.be/Overlegplatforms_Geestelijke_Gezondheidszorg_van_V/60/ggz;

http://www.overlegplatformsggz.be/Wallonie/3253/ggz; http://www.psychiatrieverband.be/

w www.juriwel.be/

x http://wallex.wallonie.be/index.php?mod=accueil;

y http://www.zorg-en-gezondheid.be/

z http://www.wallonie.be/fr/citoyens/sante-prevention-et-securite/index.html;

http://www.cocof.irisnet.be/site/fr/SiteMap/index_html;

http://www.cocof.irisnet.be/site/fr/sante/Files/DECRET_AMBU/;

aa http://www.iwsm.be/institut-wallon-sante-mentale.php?idt=1

bb http://www.kuleuven.be/lucas/; http://www.steunpuntwvg.be/;

cc Corens D. Health system review: Belgium. Health Systems in Transition,2007; 9(2): 1–172.


KCE Reports 144 Evidence Based Mental Health Services 75

7.3 GENERAL FINANCING OF THE BELGIAN HEALTH CARE

SECTOR

7.3.1 General principles

The Belgian health system is primarily funded through social security contributions and

taxations. According to the European “Health for all database” (hfa-db), in 2005 total

health expenditure as a percentage of gross domestic product (GDP) in Belgium was

9.6%, of which public health expenditure amounted to 7,1% (Avalosse 2008) 178 .

Each year since 1995, the government decides the legal growth norm applied to the

public health care system. Introduced in 1995 and expressed in real terms, this norm

has risen from 1.5% in 1995 to 2.5% in 1999 and 4.5% in 2004. Each year, a global

budget and partial budgets are fixed by the general Council and the Committee for

health Insurance where all the health care stakeholders are represented (care providers

like physicians or dentists, mutualities, organizations of employers, trade unions

employees, health care institutions like hospitals). In Conventions and Agreement

Committees, the insurers (mutualities) and the care providers organize the health

system on the field. They decide the contents of the ‘nomenclature’, the tariffs and the

co-payments for each medical activity and service. In the context of the budgetary

procedure, they have to determine, yearly, the needs of each health care sector

(specialists and general practitioners, hospitals, drugs, nursing homes, rehabilitation,

etc.). When a budget is exceeded, the members of these Committees are responsible

for the elaboration of control measures (reduction of tariffs, increase of co-payment,

revision of reimbursement conditions etc.).

Belgian health professionals are mainly remunerated through a fee-for-service system,

which applies to medical and medico-technical services (consultations, laboratories,

medical imaging and technical procedures) and paramedical activities (e.g.

physiotherapy). The basic feature of Belgian hospital financing is its dual remuneration

structure: services of accommodation (nursing units) and nursing activities in the

surgical department are financed via a fixed prospective budget system based on

diagnosis-related groups (DRGs); whereas medical, medico-technical and paramedical

services rely on the fee-for-service system.

7.3.2 The statutory insurance system

In Belgium, we can distinguish two statutory insurance systems for health care costs

covering: the ‘general system for salaried workers’ and the system for ‘self-employed’.

Beside these systems, we find the complementary insurance system, organised by the

mutualities and the ‘facultative’ insurance system organised by the mutualities and the

private companies. In 2005, it was calculated that the public health expenditures

represented 77% of the total health expenditures 178 .

The regulation and financing of the statutory insurance system belongs to the

responsibility of the federal government; and the mutualities are responsible for

reimbursement of the health care costs of their members. Since 1995, Belgian

mutualities receive a prospective budget from the National Institute for Health and

Disability Insurance (NIHDI, RIZIV/INAMI) dd to finance the health care costs of their

members. They are held financially accountable for a proportion of any discrepancy

between their actual spending and their so-called normative, i.e. risk-adjusted, health

care expenditures. The reimbursement level of services provided depends on the

employment situation of the patient (self-employed or employed, until 2007), the type

of service provided, the statute of the person who is socially insured (preferential

reimbursement or not) as well as the accumulated amount of user charges already paid.

Patients in Belgium participate in health care financing via co-payments.

dd The National Institute for Health and Disability Insurance, which acts as an intermediary between the

whole of the Social Security and the mutualualities. It plays a role in the allocation of financial resources

and in the establishment and control of current legislation.


76 Evidence Based Mental Health Services KCE reports 144

7.3.3 The complementary insurance system

It is estimated that 2,9 % (0,8 billion euros) of the net total health expenditures are

covered by the complementary insurances of the mutualities 179 . The members of the

mutualities pay compulsory or optional primes to be covered for health services and

goods not covered by the statutory insurance system. The complementary insurance is

different for all the mutualities and the ‘solidarity’ is limited to the members of the same

mutuality.

7.3.4 The private system

Beside the statutory and complementary insurance, private health insurances cover a

part of hospitalisation costs ee . In 2005, the interventions of these insurances companies

represent 2,3 % of the net total health expenditures. This private covering of health cost

is relatively marginal but increases constantly; in 1998, they covered only 1.5% of the

net total health expenditures.

7.4 GENERAL ORGANIZATION AND FINANCING OF

SUPPORT SERVICES FOR PEOPLE WITH DISABILITIES

Services for disabled persons

The regional Governments are responsible for the provision and financing of long-term

care for disabled persons: VAPH or Vlaams agentschap voor personen met een

handicap; AWIPH or Agence wallonne pour l'intégration des personnes handicapées;

DPB or Dienstelle für Personen mit Behinderung; for the specific situation of Brussels

see Appendix ff Figure A.1 and website COCOF gg . Their offer is very diverse and consists

of settings for residential care, semi-residential care, day care, short-term care, respite

care, reference centres, services for support at home, sheltered workshops (beschutte

werkplaats, entreprise de travail adapté) …

Public Welfare services

Several services depending on the level of municipalities and provinces, are in charge of

help and support in the domain of Public Welfare, e.g. services for social housing,

financial support, help at home for domestic tasks (familiale hulp, aide à domicile) etc.

These services are open to persons with several types of psycho-social problems.

7.5 ORGANIZATION OF THE MENTAL HEALTH CARE IN

BELGIUM

We focus our analysis on the general adult psychiatry. This means that we do not take

into account the child and adolescent psychiatry. We also do not focus on those care

settings that are specifically organized for elderly persons, but services for adults that

are also open to elderly persons will be included. Since in the literature review of this

report the care organization for addiction and forensic psychiatry are not included (see

chapter 2), no specific attempts were made to find information on these subjects.

However, when information on these two subjects seems to be necessary to clarify the

global context, it will also be mentioned.

The literature review in this report only deals with care organization for persons with

severe and persistent mental illness (SMI). Since it is difficult to describe the mental

health care organization on the level of a country specifically for the SMI group, the

country descriptions will include the full mental health care organization. However, the

field of prevention and health promotion will not be dealt with.

ee There exists private insurance covering also ambulatory costs but the extend of these insurances is

limited

ff for mental health care and social support in Brussels, see Appendix Figure A.2 and website COCOF

gg http://www.cocof.irisnet.be/site/fr/sante/Files/TAB_SANTE_SOCIAL_BXL_09/


KCE Reports 144 Evidence Based Mental Health Services 77

7.5.1 Historical context hh

7.5.1.1 The reform of 1990: psychiatric nursing homes, initiatives of sheltered living,

psychiatric home nursing, and consultation platforms

Like elsewhere in Europe, the Belgian psychiatric reform that was started in 1990 is

characterized by the will to take care of persons with a mental disorder out of the

hospitals, and by the movement of substitution between hospital beds and other forms

of residential or ambulatory care. The laws of July 1990 have created new care

structures: the psychiatric nursing home (PNH) (maisons de soins psychiatriques –

psychiatrische verzorgingstehuizen) and the initiatives of sheltered living (ISL) (initiatives

d’habitations protégées – beschut wonen) ii . The law of 1991 also lined out the

conditions for psychiatric hospital services to organize psychiatric home nursing (Tf)

(places de soins psychiatriques en milieu familial – psychiatrische gezinsverpleging). This

means that the person with a mental disorder lives with a foster-family supported by

professional services, but at the same time a certain number of hospital beds serve as

back-up in case the patient should need hospitalization. jj The creation of these three

new structures was accompanied by the reduction of the number of psychiatric beds by

compulsory and voluntary reconversions of hospital beds into beds in PNH and places

in ISL or Tf. In the same Laws we find also the conditions for the creation of

‘consultation platforms’ (plates-formes de concertation psychiatrique – overlegplatforms ;

see below). The most important goal of these platforms consists in the dialogue about

the regional coordination of the different existing and new forms of medical and

psychosocial supply for persons with a mental disorder.

7.5.1.2 The reform of 1999: planning of PNH, ISL and Tf

The process of reconversions was promoted by new laws edited in 1999 giving precise

conversion rate between hospital beds and from hospital beds (psychiatric beds and

other hospital beds) into PNH beds kk and ISL ll or Tf places mm . The goal of the

reconversions was to provide all types of care organizations in each region and

community. Per thousand inhabitants 0,6 beds are planned for the PNH and 0,5 places

per thousand inhabitants for the ISL. The maximal number of patients in the Tf system

was fixed on 975 for the whole country, and for these patients a maximum of 145

hospital places could be foreseen. (Additional Tf places/beds were made possible by the

law of 29-09-2000, which did not fix a maximal number of Tf places/beds anymore). It

was also decided to re-invest 10% of the economy resulting from the reconversions

back in the hospitals and services taking part in the reconversions. A part was dedicated

to the employment in the hospital (7.5% of the economy) and a part (2.5% of the

economy) to the budget of the hospital by means of an increase of the “daily fee”

(increase of the B4 part of the psychiatric hospital which is dedicated to projects of

quality promotion of psychiatric care).

hh For this historical part, we base our text mainly on the information found on the site of the Fnams

(http://www.fnams.be;

http://www.fnams.be/LOGINONE/levelone/geest_gezondheidszorg/gghp.asp)(Fédération Nationale des

Associations Médico-Sociales).

ii A.R. and A.M. 10 th July 1990

jj A.R. 10 th April 1991

kk A.R. 16 th June 1999 (MB 29 th September 1999) modified by A.R. 18 th February 2000 (MB 16 th March

2000), A.R. 14 th April 2001 (MB 26 th October 2001) and A.R. 03 rd July 2005 (MB 12 th August 2005). See

also A.R. 23 rd June 2003 (MB 07 th August 2003) and A.R. 19 th March 2007 (MB 13 th April 2007)

ll A.R. 16 th June 1999 (MB 29 th September 1999) modified by A.R. 18 th February 2000 (MB 16 th March

2000), 05 th June 2000 (MB 14 th July 2000), 14 th September 2001 (MB 26 th October 2001) and 10 th

November 2005 (MB 13 December 2005)

mm A.R. 10 th April 1991 (MB 30 th April 1991) modified by A.R. 12 th October 1993 (MB 19 th October 1993)

and A.R. 16 th June 1999 (MB 29 th September 1999)


78 Evidence Based Mental Health Services KCE reports 144

7.5.2 Third reformation wave: care circuits and networks of care

7.5.2.1 Political and legal context

The concept of Care circuits and networks of care

Already after the first reform wave of the early nineties, it was clear that additional

measures would be necessary to develop further the principles put forward at the

beginning of the reformation. Therefore, the National council for hospital supplies

(Nationale raad voor ziekenhuisvoorzieningen (NRZV), Conseil national des

établissements hospitaliers (CNEH)), an advisory committee at the Federal public

service for health, food chain safety and environment, mandated its Permanent

psychiatric working group to formulate these advices. A first advice was formulated on

15 th May 1997, followed by many others that, on request of the Ministers, have been

brought together in one synthetic document nn that has been approved on 21 st June

2002. The main principles of this document don’t rely on a reconversion but a new

content for the mental health care organization in Belgium is formulated.

A specific legal context for some of these new principles had already been created in

January 2002, to define the concepts of ‘networks of care’ and ‘care circuits’ oo . A ‘care

network’ is a whole (i.e. an aggregate) of caregivers, care organizations and services

depending on the federal authority, which proposes to a ‘target group’ one or several

care circuits. A ‘care circuit’ is a whole of care programs and services depending on the

federal authority, organized by a network of care organizations, and dedicated to one

‘target group’ or a ‘sub target-group’.

2002: Declaration on the future mental health care policy

On 24 th June 2002, the Ministers responsible for Health at the federal, regional and

community level, all signed a common declaration about the future mental health care

policy. pp This declaration is based on the advice of the NRZV/CNEH (21 st June 2002);

and it refers to the WHO report (2001) on the challenging evolution of the psychiatric

and psychological problems in the world. The declaration contains 4 main points:

1. The need of a new concept of mental health care

The Ministers insist strongly to give a central place in the organization of care to the

person with a mental disorder. To realize this and to optimize mental health policy, they

propose a closer collaboration between all the authority levels by the organization of a

Task Force. This Task Force should become responsible for the elaboration of

proposals submitted to the inter-ministerial conference.

2. The basic organizational principles of the future mental health care

Mental health care has to be organized around the needs of the person with a mental

disorder and, if possible, in his natural living environment. Care should be adjusted to

the specific needs of each person with a mental disorder and his family (“tailored care”).

Three main target groups should be distinguished: children and adolescents, adults, and

the elderly. A specific ‘care circuit’ has to be developed for each of these groups. The

future care supply will be developed starting from the actual system which has to be

adapted and completed, to lead to a coordinated system of services, in which continuity

of care is an important element. This makes the development of “care networks”

between different service providers and professionals necessary. Coordination and

collaboration between the different authority levels should also be put in place. Finally,

prevention and promotion of mental health will be developed to guarantee the welfare

of all citizens.

nn

https://portal.health.fgov.be/pls/portal/docs/PAGE/INTERNET_PG/HOMEPAGE_MENU/GEZONDHEIDZ

ORG1_MENU/OVERLEGSTRUCTUREN1_MENU/NATIONALERAADZIEKENHUISVOORZIENINGEN

1_MENU/NATIONALERAADZIEKENHUISVOORZIENINGEN1_DOCS/2002%2007%2010%20-

%20NRZV%20D%20PSY%20209-2%20NL.PDF

oo See the article 9ter of the hospital law introduced by the Law of 14th January 2002

pp See MB 23rd May 2005


KCE Reports 144 Evidence Based Mental Health Services 79

3. Priority will be given to children and adolescents (on request of the Task force

enlarged on 24-5-2004 to persons of any age, suffering from a chronic and

complex psychiatric disorder).

2005: the concept of Therapeutic projects and Transversal

Conversations

In May 2005, the federal Minister of social affairs and public health Rudy Demotte,

published a document qq about mental health care organization, where he explains the

challenges addressed at the mental health care system. He concludes that “Therapeutic

projects” should be developed, which are meant to try out new initiatives aiming at

creating care circuits and care networks and preparing a structural and definitive

implementation of care circuits and care networks for persons with a chronic and

complex mental disorder. This should enable a more integrated approach to guiding

these patients through the different types of care provision. Although the definitions of

“care circuit” and “care network” only include services under federal authority, the

Minister proposes to include services and care organisations depending on regional or

community authorities. Whereas the Therapeutic projects are meant to prepare circuits

and networks at the patient level, it is also necessary to prepare these circuits and

networks at an organizational and population level; therefore the “Transversal

Conversations“ will be developed (see further).

On 23 Dec 2009, a Royal decree rr (article 107) concludes that “care networks” and

“care circuits” can be financed temporarily and on an experimental base (“experimental

projects”), according to the national law for hospital funding. This opens the way to

anchor the Therapeutic projects to the regular hospital funding. The first proposals for

the organization of such experimental projects are underway ss

7.5.2.2 Third reformation wave: implementation

The Consultation platforms

In 1991, a first step towards the general idea of developing continuity of care and

collaboration between different mental health services had already been realized by the

creation of the “consultation platforms” tt active in all the regions: five in the Flemish

region, one in the Brussels region, seven in the Walloon en German regions. These

platforms are financed by the Federal Government. They aim at consulting with the

different mental health care organizations in their region to optimize the diversity and

complementarity of the care supply, and to promote collaboration. Each platform

consists of psychiatric services of general hospitals, psychiatric hospitals, PNH, ISL,

ambulatory mental health care centers and rehabilitation centers for persons with

mental disorders, belonging to the region of the platform. Each platform also has to

organize an ombudsservice to mediate between patients raising a complaint and the

care providers of the region. One federal umbrella platform (connected with the

Federal public service for health, food chain safety and environment) is in charge of the

contacts between the 13 platforms and the policy makers.

qq

rr

https://portal.health.fgov.be/pls/portal/docs/PAGE/INTERNET_PG/HOMEPAGE_MENU/GEZONDHEIDZ

ORG1_MENU/GESPECIALISEERDEZORGEN1_MENU/GEESTELIJKEGEZONDHEID1_MENU/PUBLICA

TIES41_HIDE/PUBLICATIES41_DOCS/PSY_2005_001_BELEIDSNOTADEF_GGZ_25_04_05%20.PDF

See MB 7nd November 2008; amendments of 23th Dec 2009 (article 107)

ss https://portal.health.fgov.be/portal/page?_pageid=56,512828&_dad=portal&_schema=PORTAL

tt Plates-formes de concertation psychiatrique – Overlegplatformen ;

https://portal.health.fgov.be/portal/page?_pageid=56,512646&_dad=portal&_schema=PORTAL;

www.overlegplatformsggz.be;

http://www.fnams.be/LOGINONE/levelone/geest_gezondheidszorg/ggopso.html;


80 Evidence Based Mental Health Services KCE reports 144

Pilot projects started in 2001

In 2001, the federal Government started up several pilot projects uu as a next step to

realize care circuits and networks. The Federal public service for health, food chain

safety and environment, and more specifically its Service of psychosocial health care

(Dienst psychosociale gezondheidszorg, Service des soins de santé psychosociaux vv )

hosts and finances these projects. They are meant to try out new organisational

structures or a specific care offer; some of them are set up around a specific problem

group. If the projects succeed, policy makers can be advised on the necessary conditions

before the new care structure is legally adopted.

Of all the different projects, the projects ‘psychiatric care for patients in the home

environment’ became by law linked to the ISL and structurally financed by the Royal

decree of 17 th March 2009 ww . On the other hand, so far only the projects ‘activation’

(see below) have been put to an end and left to the Ministry of Work, because only 8%

of the participants returned back to work. The other projects have been, as far as

possible, included in the Therapeutic projects started in 2007 (see further). Besides the

projects for adults described below xx (including projects related to addiction), there

were 4 projects for children and adolescents.

• By means of supportive counselling, the 19 projects ‘activation’ focused on

stimulating the social inclusion of chronically mentally ill persons in the field

of work and education. These projects had to be established by an initiative

of sheltered living, but other target groups than the ISL residents had to be

included as well.

• The 29 projects ‘psychiatric care for patients in the home environment’ aim

at making care providers in home care aware of this target group, coaching

them, and guaranteeing co-ordination of the care. The final purpose is an

improved co-operation between the actors of the regular home care and the

actors in mental health care. This can help, for example, to avoid admission in

hospital in times of crisis. The participation of an initiative of sheltered living

is compulsory.

• In the 4 projects ‘persons with severely disturbed behaviour and/or

aggressive behaviour (SGA)’ separate units of 8 beds each are established for

this target group. They offer specific programs for a limited period aiming at

decreasing the most severe behavioural disturbances.

• The 6 projects ‘commitment/internment’ provide an intensive clinical

treatment in a separate unit of 8 beds each, for detainees free on probation,

aimed at reintegration in society. There is an additional financial support from

the federal Government department of Justice.

• The 2 projects ‘double diagnosis’ offer a specific treatment for patients with

an addiction problem in combination with psychotic psychiatric problems.

The purpose is to at least stabilize the patient and if possible to realize a

transfer to another relevant ambulant or residential setting.

• Nine pilot projects established crisis units for patients with addiction

problems and a case manager has been implemented in these units. The short

treatment aims at resolving the crises; the case manager is responsible for the

continuity of care during the admission and at discharge.

• The pilot project ‘implementation of the function care co-ordinator for the

treatment of persons with addiction problems’ is embedded in the 13

consultation platforms. The purpose is to facilitate care trajectories.

uu see also KCE report 84 “Long stay patients in T-beds”, p 149

vv https://portal.health.fgov.be/portal/page?_pageid=56,512828&_dad=portal&_schema=PORTAL

ww see RD 17th March 2009

xx https://portal.health.fgov.be/portal/page?_pageid=56,911986&_dad=portal&_schema=PORTAL


KCE Reports 144 Evidence Based Mental Health Services 81

• The projects ‘discharge management in psychiatric hospitals’ try to establish a

bridge between hospitals and the domestic environment of a patient in order

to avoid the risk of discontinuity of care. This is realized through systematic

and patient oriented preparation of the discharge in consultation with the

extramural actors.

• Three projects on “care for persons that committed an attempt of suicide”

aim at developing education for hospital and first line professionals.

• One project organizes a mobile team (“outreach”) providing mental health

care to homeless people.

• One project evaluates the possibility to diminish the number of persons

seeking help because of a psychiatric crisis at the emergency department. The

project supports first line professionals (family doctors...) in charge of

persons in crisis by telephone or by providing on-line information (referral

possibilities, treatment guidelines...), so that referral to the hospital possibly

can be avoided.

The Therapeutic projects started in 2007

In April 2007, eighty-two TP or Therapeutic projects yy were launched zz . Each TP

includes at least one partner organization of the first-line (family doctor, home nursing,

home care coordinating service (geïntegreerde dienst voor thuiszorg (GDT) services

intégrés de soins à domicile (SISD)), second-line (mental health care centre (centrum

voor geestelijk gezondheidszorg (CGGZ), service/centre de santé mentale (SSM)) and

third-line level (psychiatric service of general hospital or psychiatric hospital). The TP,

based on local initiatives (bottom-up approach), are subdivided in projects for children,

for adults and for elderly, and many different target-groups are included (Psychotic or

depressive disorders, borderline or other personality disorders, attention-deficit-andhyperactivity

disorder (ADHD), combined psychiatric problems and mental retardation,

addiction, forensic psychiatry, social psychiatry...). Four meetings per patient per year of

the different participating care organizations of the project are mandatory. The projects

are run for three years, and scientific follow-up should make an objective evaluation

possible. Reimbursement is foreseen by the NIHDI (RIZIV/INAMI) and includes a global

fee for the coordination of the project, as well as a fee for each meeting of the

participating care organisations where the problems and the coordination of care for

one specific patient are discussed. A significant budget has been contributed by the SPF,

The NIHDI budget amounts to +-Euro 2 200 000/year.

Besides the patient-centred meetings within one project, there are general meetings for

all projects of a specific cluster; in these meetings the different care organizations of the

cluster projects can participate, as well as patient and family organizations. The purpose

of these ”Transversal meetings” aaa is to discuss the general approach in the projects, the

specific added value of the network and care coordination approach, as well as the

encountered organizational problems. bbb The meetings are organized by the regional

consultation platforms. Evaluation of the meetings and general conclusions are also

under the responsibility of the regional consultation platforms. The Federal public

service (FPS) for health, food chain safety and environment finances these meetings and

the gathering of the necessary data to evaluate the projects; the yearly budget amounts

to +-Euro 2 795 000. The Federal health care knowledge centre (KCE) is involved in the

scientific evaluation of the data.

It should be noted that in 2007, as much as possible, the existing Pilot projects that

started in 2001, were included in the TP.

More details on the TP are published in other KCE reports (see KCE reports 103 and

123)

yy http://www.riziv.be/care/nl/mental-health/therapeuticProjects/

zz see Royal decree of 22nd Oct 2006

aaa http://www.transversaaloverleg.be/

bbb http://www.transversaaloverleg.be/documenten/Basisdocumenten/NRZV%20-

%20deeladvies%202%20en%203%20over%20TO.pdf


82 Evidence Based Mental Health Services KCE reports 144

The “Experimental” projects

On 23 Dec 2009, a Royal decree (article 107) concludes that “care networks” and “care

circuits” can be financed temporarily and on an experimental base, according to the

national law for hospital funding. Based on this Decree, the SPF will develop

“experimental projects” as a temporary step to realize care circuits and networks

within the structures of the hospital financing ccc . The “therapeutic projects” will be put

to an end. The collaboration of the regionally funded ambulatory mental health care

centers has been assured by an agreement of the Interministerial conference.

Examples of projects not funded by the government

Apart from the new initiatives supported by the federal Government, some care

organizations with a substantial experience in psychiatry start one or more projects in

domains that are not (yet) or not fully covered by the Government. Many examples

exist; a few of them will be mentioned below.

• The VRINT project ddd started in Jan 2009 and is run by the University

Psychiatric services centre “St Jozef Kortenberg”. A multidisciplinary team,

embedded in a local network of other care providers, can be contacted for

an early diagnosis and/or first intervention in case of early psychosis

(adolescents and young adults of 15-30 years). The goal of the team is to

intervene early, at the first signs of a psychosis, with the aim to improve later

outcome. Also in Antwerpen, Halle-Vilvoorde, Sint-Niklaas and Brugge, a

similar project (VDIP-team) has been started.

• In 2006, a project “Assertive Community Treatment (trACTor)” was

launched by the psycho-social centre “St-Alexius-Elsene” eee . The team

coordinates and provides multidisciplinary interventions in the community for

persons with a chronic mental disorder, usually associated with several social

problems as well. The pilot project aims to develop guidance for other

starting ACT-teams in Belgium. Initially it was funded by the “Koning

Boudewijn/ Roi Baudouin Foundation” and a pharmaceutical company; but

since 2007 funding is foreseen in accordance with the terms of the

Therapeutic projects.

• Between 2003 and 2007 the province of East-Flanders subsidized a project on

mental health care circuits for the elderly. The care circuits that were

developed during the project are still continued and follow-up is provided by

the East Flanders consultation platform. fff Participating care providers learned

that it is better to provide mental health care support in the usual care circuit

for elderly people, rather than transferring these persons with mental health

problems to the specialized mental health care services.

• The “Netwerk psychiatrische zorg in de thuissituatie, Regio Groot-Gent” ggg

participates in the governmental projects ‘psychiatric care for patients in the

home environment’ that are linked to the ISL, but additionally to the

personnel financed by the Government (2 FTE), 2.6 other FTE are financed

by the partners of the Network.

ccc http://www.health.belgium.be/eportal/Healthcare/index.htm

ddd http://www.vrint.eu/; http://www.vvponline.be/nl/activiteiten/2009/project_vrint_vroegtijdige_interventie_bij_vroege_psychose-290.html

eee http://www.psc-elsene.be/

fff http://www.popovggz.be/documenten/Activiteitenverslag%202008.pdf

ggg http://www.psytzgent.be/netwerk%20psychiatrische%20thuiszorg%20Gent.htm


KCE Reports 144 Evidence Based Mental Health Services 83

7.5.3 Data collection, scientific institutes

Data collection

• - The collection of Minimal psychiatric data (MPD) (Minimale psychiatrische

gegevens (MPG), Résumé psychiatrique minimum (RPM)) is obligatory for

Psychiatric hospitals, psychiatric departments of general hospitals, PNH and

ISL. The anonymous data of all stays of residents is passed on to the federal

Government (Federal public service for health, food chain safety and

environment hhh ). The data is collected at the beginning and at the end of

residential treatment (a stay), as well as after each significant period in the

treatment (e.g. when the residents moves to another treatment unit) or at

least each 6 months.

The data collection is extensive, although no validated outcome measures are included:

patient socio-demographic data are detailed, a lot of attention is paid to functional

impairments (and not only medical diagnosis) and to all types of help the residents might

need (not only medication). Collected are:

socio-demographic data, living environment before start of the residential care,

educational level and occupation, psychiatric diagnosis (DSM-IV), details of the existing

problems on several domains (psychological, social, relational, physical...), therapeutic

goals (stabilization of symptoms, improvement, total cure), relevant professional acts

during stay (help with activities of daily living, supervision on safety, diagnostic and

therapeutic acts (psychotherapy, group therapy, physiotherapy...); medication classes

prescribed, living environment after leave (at the end of stay).

Scientific institutes, Reference centers for mental disorders

• -Walloon Institute for Mental Health (Institut Wallon pour la Santé Mentale,

IWSM iii ): founded in 2002, this institute brings the different stakeholders in

mental health care together, including professional associations and policy

makers as well as associations for persons with mental disorders and their

family. The aim is to discuss and reflect on issues of treatment, organization

as well as ethics. The IWSM is also responsible for research, education and

dissemination of information. It is composed of a multidisciplinary team, and

funded by the Walloon region.

• - Reference centres for mental disorders: the Walloon regional Government

decided by Decree on 3 rd April 2009, to create and fund (a) reference

centre(s) (centre(s) de reference en santé mentale). These centre(s) are/is

responsible for the care coordination between ambulatory centres for mental

health care and other mental health care providers; they are/ it is also

responsible for education and support of these local centres, and eventually

for research and data analysis.

• -Several other research teams, mostly linked to a university, are active in the

field of (organization and financing of) mental health care.

7.5.4 Mapping of existing services

We use the ‘Service Tree’ developed by Johnson et al. to map the mental health

services 5 . This ‘Tree’ distinguishes five main different structures of mental health

services: secure, residential, day & structured activity, out-patient & community and selfhelp

& non professional services. The second, third and fourth structures are developed

as a tree to take into account the differences between acute and non-acute cares,

emergency and continuing care but also the care duration and intensity (and eventually

whether mobile care supply is possible or not).

hhh https://portal.health.fgov.be/portal/page?_pageid=56,512879&_dad=portal&_schema=PORTAL

iii http://www.iwsm.be/institut-wallon-sante-mentale.php?idt=1


84 Evidence Based Mental Health Services KCE reports 144

We present a synthetic table of all the existing services applying the ESMS tree and we

describe the organizational and financial aspects of each of them in the following

sections. We distinguish ‘Full mental health services’ depending of the psychiatric

sector, from the Mixed services (‘Residential mixed services’ and ‘Mixed support

teams’). We find ‘full mental health services’ in almost all categories of the Service Tree

developed by Johnson (the figures in brackets refer to the synthetic Table). Residential

mixed health services and mixed support health and social teams concern a broader

group of patients or persons with social problems. The mixed teams are only

ambulatory services. These types of services will be generally dealt with.

Only services for which a specific legal context exists will be mentioned in this Service

tree. Pilot projects, therapeutic projects or other experimental settings will not be

mentioned here.

Table: Synthetic presentation of the ESMS tree

SECURE (1)

RESIDENTIAL Generic acute Hospital (2)

Non-hospital (3)

Non-acute Hospital (4) Time limited (4.1)

Indefinite stay (4.2)

Non-hospital (5) Time limited (5.1)

Indefinite stay (5.2)

DAY & STRUCTURED Acute (6)

ACTIVITY

Non-acute (7) High intensity (7.1)

Low intensity (7.2)

OUT-PATIENT & Emergency care (8) Mobile (8.1)

COMMUNITY

Non-mobile (8.2)

Continuing care (9) Mobile (9.1)

Non-mobile (9.2)

SELF-HELP & NON-PROFESSIONAL (10)

7.5.4.1 The ‘full mental health’ services

We begin with the list of the ‘full mental health services’; the numbers refer to Table 6:

• Full time hospital care : 2 & 4

• Part-time hospital care (night or day): 4 & 7

• Psychiatric home nursing : 5

• Initiatives of sheltered living (initiatives d’habitations protégées – beschut

wonen) : 5

• Psychiatric nursing home (maisons de soins psychiatriques - psychiatrische

verzorgingstehuizen) : 5

• Therapeutic communities, half-way houses, night centres : 5

• Day centres, therapeutic clubs : 7

• Centres for crisis intervention : 8.2

• Outreach (street workers) for drug addiction: 8.1 and 9.1

• Mental health centers (centres ou services de santé mentale – centra voor

geestelijke gezondheidszorg) : 9.2

• Rehabilitation centers (centres de réhabilitation – revalidatiecentra) : 9.2

• Postcure care : 9.2

• Ambulatory care givers (psychiatrists, psychotherapists, psychiatric nurses) : 8

& 9


KCE Reports 144 Evidence Based Mental Health Services 85

7.5.4.2 The ‘residential mixed’ services (5.1 & 5.2) and the “mixed support teams” (7

& 9)

Services for disabled persons

The regional Governments (VAPH or Vlaams agentschap voor personen met een

handicap; AWIPH or Agence wallonne pour l'intégration des personnes handicapées;

DPB or Dienstelle für Personen mit Behinderung; the Service Bruxellois francophone

des personnes handicapées (SBFPH)) are responsible for the provision of long-term care

for disabled persons. This offer is very diverse and consists of settings for residential

care, semi-residential care, day care, short-term care, respite care, reference centres,

services for support at home, sheltered workshops (beschutte werkplaats, entreprise

de travail adapté) …

Different types of handicaps are accepted in these “mixed” settings, e.g. mental

retardation and physical handicaps. However, persons with a primary diagnose of a

mental disorder (schizophrenia, severe depressions…) do not belong to the target

groups under the responsibility of the regional Governments. This is probably a

consequence of the historical reconversion operations in the psychiatric sector.

One exception are persons with autism spectrum disorders, which do fall under the

responsibility of the regional Governments, as concerns long-term care. Probably this is

due to the fact that they are considered to suffer from congenital developmental

disorders with the first signs and symptoms appearing early in life, as opposed to

persons with “classical” primary diagnoses of mental health disorders. A group for

which it is less clear where they can find long-term care, is the group of persons with

Acquired brain injuries.

Services of Public Welfare

Several services depending on the level of municipalities and provinces are in charge of

help and support in the domain of Public Welfare, e.g. services for social housing,

financial support, help at home for domestic tasks (familiale hulp, aide à domicile) etc.

These “mixed” services are also open to persons with mental disorders, but no figures

on the number of users with a mental disorder are available.

Some initiatives have been taken to improve the collaboration between these services

for Public Welfare and the ambulatory mental health care services, e.g. the temporary

financial support for this kind of collaboration from the Flemish Ministry for Welfare,

Public Health and Family (2008) jjj

7.5.5 The ‘Mental health care tree’ in Belgium

A table with an overview of available services in Belgium is presented in chapter 14.1.6.

7.5.5.1 Secure services (1)

Out of scope of this report.

7.5.5.2 Residential mental health services

• Residential, generic Acute; hospital (2) or non-hospital (3)

Hospitals with units with letters A (day and night), a1 (day treatment) and a2 (night

treatment) (see also further Residential, non-acute, hospital (4)), can provide residential

care in case of crisis. Specific hospital emergency units for psychiatric patients

(addiction) currently only exist as experiments.

• Residential, Non-acute

o Residential, non-acute, Hospital (4)

jjj http://www.zorg-en-gezondheid.be/nieuws/700000_voor_CGG.aspx


86 Evidence Based Mental Health Services KCE reports 144

In Belgium, hospitals can be classified into two categories: general and psychiatric. In

2005, there were 116 were general (non-specialized) hospitals kkk and 69 psychiatric

hospitals. Funding of Belgian hospitals belongs to the responsibility of the federal

Government.

In both types of hospitals, one can find several types of units (K for children (not further

described), A or T for adults, Sp6 for elderly). The indices with capital letters (A, T)

characterize residential beds (full time hospitalization) and the ordinary letters (a, t)

characterize beds where the patients find a place for the day (a1, t1) or the night (a2,

t2) (part time hospitalization).

• Units for adults with letters A (day and night), a1 (day treatment) and a2

(night treatment) to observe patients, to start or change a treatment (or to

provide care in case of crisis, see “Generic acute (2)).

• Units for adults with letters T (day and night), t1 (day treatment) and t2

(night treatment) where the treatment aims at a maximizing the (possibility

of) social reintegration.

• Units for psychogeriatric care and rehabilitation (Sp6), meant for older

persons with physical and mental health problems. The treatment intends a

physical, mental and social recovery as good as possible.

• Units for psychogeriatric care named T-Vp (only in psychiatric hospitals), also

meant for older persons with physical and mental health problems.

After a discharge from a psychiatric hospital, a patient can get an ambulatory follow-up

treatment in the hospital during three months with a possibility of prolongation (system

of post treatment, see further).

An overview for the year 2007, for Belgium and for the regions of Flanders, Walloon

and Brussels, can be found in Table 7.1. Note that in 2007 Belgium had 10 584 534

inhabitants, of whom 57.8% (6,1 million) in the Flanders region, 32.5% (3,4 million) in

the Walloon region and 9.7% (1,0 million) in the region of the capital Brussels. lll

It is clear from table 7.2 that many more places are available in Psychiatric hospitals (Abeds

as well as T-beds, 82%; A-beds 66%, T-beds 98%) as compared to Psychiatric

services of general hospitals (18%); the latter provide almost only A- or a-beds. By law,

per thousand Belgian inhabitants 0.9 places are planned for T-beds (+-9000 places for

Belgium) and 0.4 for t1 (day treatment); this means that the legal norm for T-beds has

not been reached.

In Psychiatric hospitals 15% of the places are reserved for part-time hospitalization; in

Psychiatric services of general hospitals 10%.

kkk excluding specialized hospitals and geriatric hospitals.

lll http://www.plan.be/admin/uploaded/200805081112550.pp105_nl.pdf


KCE Reports 144 Evidence Based Mental Health Services 87

Table 7-1: Available places for persons with a mental disorder in 2007 in

Belgium and in the region of Flandres, Walloon and Brussels. (Source:

Federal public service for health, food chain safety and environment)/ (*):

Additionally 15 night- or week-end places are available in Brussels (2009)

under a NIHDI 772-Convention.

Belgium Flandres Walloon Brussels

Psychiatric hospitals

(Residential+Day/night)

Psychiatric hospitals

Residential

(A+K+T+Sp6)

Psychiatric hospitals

Day or Night Treatment

Psychiatric Departments

General hospitals

(Residential+Day/night)

PD General hospitals

Residential

(A+K+T)

PD General hospitals

Day or Night Treatment

Psychiatric

Nursing Home

13443 8461 4021 961

A 4686 2884 1354 448

K 474 209 205 60

T 5626 3415 1916 295

Sp6 576 405 171 0

T-Vp 764 644 120 0

11362 6913 3646 803

2081 (*)

1548 375 158

3010 1537 1075 398

A 2404 1240 854 310

K 214 131 35 48

T 90 0 90 0

Sp6 583 154 286 143

T-Vp 0 0 0 0

2708 1371 979 358

302 166 96 40

3241 2240 799 202

Running-down Places 781 738 43 0

Permanent places 2460 1502 756 202

Initiatives Sheltered Living 3671 2486 751 434

TOTAL 23365 14724 6646 1995


88 Evidence Based Mental Health Services KCE reports 144

Hospitalization

Adults

Psychiatric

hospitals

Total

Table 7.2: Hospital supply in Belgium for persons with mental disorders,

adults and elderly (places, 2007) (Source: Federal public service for health,

food chain safety and environment)-NA: not available

Full-time

(places)

Fulltime

(%)

Part-time

Day/Night

(places)

Part-time

Day/Night

(%)

Total

(places)

10.888 81 2081 87 12.969 82

Total

(%)

of which acute 4686 66 NA NA NA NA

of which nonacute

General

5626 98 NA NA NA NA

hospitals

Total

2494 19 302 13 2796 18

of which acute 2404 34 NA NA NA NA

of which nonacute

90 2 NA NA NA NA

Total

Total/100.000

13.382 100 2383 100 15.765 100

general

population

of which

127,4 -- 22,7 -- 150,1 --

acute/100.000

general

population

67,5 -- NA -- NA --

o Residential, non-acute, Non-hospital (5)

The initiatives of sheltered living (ISL) are a first possibility of residential non-acute

care. An initiative of sheltered living is meant to house and support mentally ill persons

not in need of a fulltime hospital treatment but, for psychiatric reasons, in need of

specially adapted activities or professional help. Consequently the target group consists

of chronically mentally ill but stabilized persons that cannot yet be fully reintegrated in

society. The professional support aims at maximizing the independence of residents by

learning them social and administrative skills, organizing useful time spending and

stimulating contacts with the home environment. An ISL can shelter between 3 patients

and 10 patients; 20% of the places have been foreseen for persons living individually.

The professional team is composed by a specialist in (neuro-)psychiatry and per 8

inhabitants one FTE qualified as social nurse, psychiatric nurse, psychologist,

criminologist, social assistant or occupational therapist.

In 2007, there are 3671 Belgian places (see Table 7.1). This means 34,9 places/100.000

population. By law, per thousand Belgian inhabitants 0.5 places are planned for the ISL

(+-5000 places for Belgium) mmm ; this means that the legal norm has not yet been

reached.

Funding of the ISL belongs to the responsibility of the federal Government, through the

NIHDI (RIZIV/INAMI). This is remarkable, since initiatives of sheltered living for other

types of disabled persons, e.g. mentally retarded or physically handicapped persons,

belongs to the responsibility of the regional governments nnn (VAPH or Vlaams

agentschap voor personen met een handicap; AWIPH or Agence wallonne pour

l'intégration des personnes handicapées ; DPB or Dienstelle für Personen mit

Behinderung; for the specific situation of Brussels see Appendix Figure A.1 and A.2 and

website COCOF ooo . Probably this situation is the consequence of the reconversion

operations that took place in the nineties and the first years of this century.

mmm See A.R. 10 th July 1990

nnn http://www.vaph.be/vlafo/view/nl/; http://www.dpb.be/; http://www.awiph.be/

ooo http://www.cocof.irisnet.be/site/fr/sante/Files/TAB_SANTE_SOCIAL_BXL_09/


KCE Reports 144 Evidence Based Mental Health Services 89

The psychiatric nursing homes (PNH) are a second type of non-acute, non-hospital

residential care. The regulation concerning the psychiatric nursing homes mentions

explicitly that this type of setting is meant to offer care allowing shortening or avoiding a

hospital stay. The emphasis is put on care (and not on cure) by activating the remaining

capacities of residents and organising and offering meaningful activities during the day in

a domestic atmosphere. There are two target groups: stabilized chronically mentally ill

persons and mentally disabled persons. In both cases the patients require permanent

support, but are not in need of hospital treatment or permanent psychiatric

surveillance. Yet they are not eligible neither for an initiative of sheltered living nor for a

classical nursing home for disabled persons due to their psychiatric condition.

In 2007, there are 3241 Belgian places or 30,9 places/100.000 population (see Table

7.1). Due to the legal instructions for the reconversion actions in 1990 and 1999, some

of these places are running-down, which means that the resident taking this place will

not be replaced after he left the PNH. A total of 781 places is running-down.

By law, per thousand Belgian inhabitants 0.6 places are planned for the PNH (+-6000

places for Belgium); this means that the legal norm has not yet been reached. Long

waiting lists are reported ppp . Funding of the PNH belongs to the responsibility of the

federal Government, through the NIHDI (RIZIV/INAMI). As for the ISL, this is

remarkable, since initiatives of this type for other categories of disabled persons, e.g.

mentally retarded persons, belong to the responsibility of the regional governments.

The KCE report n°84 commented on the estimated out-of-pocket payments for the

residents in PNH (and ISL), which are much higher than estimated out-of-pocket

payments in T-hospital beds; for the Government the reverse is true. It has been

estimated that there exist structural problems with the financing of several types of

psychiatric residential care organizations; but this is out-of-scope of this report.

Psychiatric home nursing (Tf), a third type of non-acute residential care, was

created by the Law in 1991 qqq . Two psychiatric hospitals (one in Flanders (Geel) and one

in Wallonia (Lierneux)) organize home nursing for persons with a mental disorder. This

is a form of hospitalization for persons with mental disorders in need of constant

support. The patient participates in the family live of a foster family and receives the

care and support he needs. This care and support depends on a hospital psychiatric

service and is provided by a multidisciplinary team depending on the hospital.

Sometimes, general practitioners or ambulatory nurse services can also intervene. In the

hospital, a minimal number of beds are reserved to the patients in observation, waiting

for a sheltering family or to compensate for a temporary or definitive incapacity of the

family rrr .

In 2007, there are in Belgium 705 Tf-places in foster families, connected to 145 hospital

places. This means 6.7 places/100.000 population.

A special type of Residential, non-acute, non-hospital settings are the Therapeutic

Communities (TC) (Therapeutische gemeenschap, Communauté thérapeutique). The

NIHDI finances TC under an agreement in which the conditions for reimbursement are

stipulated (Convention 773-residential); in 2009 there were 369 places in Belgium or 3,5

places/100.000 population (see Table 7.4). In these TC, persons with an addiction

problem live together, usually in small units of up to 10-15 persons, and try to

overcome their problems with the help of each other and the professionals attached to

the TC. A stay in a Therapeutic community can be followed by a stay in a “Half-way

house”, that still offers residential treatment but residents participate already more in

every-day life. These Half-way houses usually depend on a Therapeutic community.

ppp http://www.senate.be/www/?MIval=/index_senate&LANG=nl

qqq A.R. 10 th April 1991 (MB 30 th April 1991)

rrr The number of beds (labelled Tf) represent minimum 15% of the total of places in foster families


90 Evidence Based Mental Health Services KCE reports 144

Other Residential, non-acute, non-hospital settings for time-limited stay

depending on the NIHDI are open to several types of mental disorders; they aim at

psycho-social rehabilitation for persons with a mental disorder that have difficulties with

activities of daily living, professional or social functioning (NIHDI-convention 772residential).

In 2009, there were 89 places available or 0,8 places/100.000 population,

see Table 7.3.

Within the framework of “mixed services” for persons with several types of

psychosocial problems, a special type are Night centres for persons with psychosocial

problems that need sheltering and help during the evening and at night, but have regular

activities or work during the day.

Table 7.3: NIHDI agreements (Conventions 772) for residential non-hospital

services and ambulatory rehabilitation of persons with mental disorders

(Source: NIHDI 2009). (*): places x 8,3; extrapolation based on NIHDI study

1999.

Convention 772 Flanders Brussels Walloon

region

Total

Belgium

Total/100.000

population

Residential

Full time

places

Part-time

31 43 15 89 0,8

(night, WE)

places

-- 15 -- 15 NA

Ambu- places 99 172 111 382 3,6

latory users/year (*)

~822 ~1428 ~921 ~3171 ~30,2

Table 7.4: NIHDI agreements (Conventions 773) for residential non-hospital

services and ambulatory rehabilitation of persons with addiction problems

(Source: NIHDI 2009). (*): places x 8,3; extrapolation based on NIHDI study

1999.

Convention 773 Flanders Brussels Walloon

region

Total

Belgium

Total/100.000

population

Residential

Full time

places

179 51 139 369 3,5

Ambu- places 334 114 118 556 5,3

latory users/year (*)

~2772 ~946 ~979 ~4697 ~44,7

7.5.5.3 Day and structured activity

• Day and structured activity, Acute (6)

No information found

• Day and structured activity, Non-acute (7)

To this category belong several types of services; the first is the Day hospital (also see

Table 4-1). Of the 2383 places for part-time hospitalization in Belgium, less than 1/10 th is

used for night hospital services. In 2006, 11.562 persons sss used day-hospital services, or

110 users/100.000 population/year.

Within the framework of the Belgian federal health insurance (NIHDI) several types of

ambulatory rehabilitation centres are established, a few of them addressing persons with

a mental disorder, including persons with addiction. Although the main aim of these

rehabilitation centres is to provide a temporary service with a specified therapeutic

goal, they are mentioned here because some of them function as Day centres (also

named “activity centres”), providing long-term activities during the day for their

target group.

sss Source: Federal public service for health, food chain safety and environment, MPG-registration,

“Actualisatie van Meerjarenstatistieken van de residentiële geestelijke gezondheidszorg Minimale

Psychiatrische Gegevens 1999 – 2003 met

MPG2006”.


KCE Reports 144 Evidence Based Mental Health Services 91

In ambulatory Convention 772 centres (psychosocial rehabilitation), 382 places or 3,6

places/100.000 population or about 30,2 users/100.000 population were available in

2009 (see Table 7.3). In ambulatory Convention 773 centres (addiction problems),

another 556 places or 5,3 places/100.000 population or about 44,7 users/100.000

population were available (see Table 7.4).

Some other Day centres are not subsidized by the NIHDI, it is not always clear how

exactly they are financed (e.g. “De Link” at Beringen).

In the Walloon region the “centres/services de santé mentale” (SSM) can organize

“Therapeutic clubs” (Club thérapeutique) ttt , in which day activities are organized for

people with severe or chronic mental disorders. The Walloon region is responsible for

funding the largest part of the costs (see further).

Several websites of large care organizations mention that they provide support to

persons of their target group that need support to get (back) to work. Often they

rely on other care providers for this kind of services, e.g. on Public Welfare Centres

(CPAS) (Openbaar Centrum voor Maatschappelijk Welzijn (OCMW), Centre Public

d'Action Sociale (CPAS)); these centres fall under the responsibility of the local

authorities (municipalities).

7.5.5.4 Out-patient and community mental health services (MHS)

• Out-patient and community MHS, Emergency care, mobile (8.1)

Some local experiments exist (e.g. region of Leuven)

• Out-patient and community MHS, Emergency care, non-mobile (8.2)

Centres for crisis intervention for the target group of addicted persons are

subsidized by the NIHDI; and Mental health care (MHC) centres (see further) can also

provide this service. No separate figures were found.

• Out-patient and community MHS, Continuing care (9)

o Out-patient and community MHS, continuing care; Mobile (9.1)

Some MHC (see further) experiment with outreach teams. A few teams providing

outreach to drug addicted persons (street workers) whether homeless or not, are

subsidized by the NIHDI. Several Public Welfare Centres (CPAS) or centres supported

by the provinces also provide help to drug users, including outreach.

o Out-patient and community MHS, continuing care; Non-mobile (9.2)

The mental health care centers (MHC) (centres ou services de santé

mentale uuu – centra voor geestelijke gezondheidszorg vvv ) www provide ambulatory

diagnostic evaluation and treatment, and provide a follow-up of all the persons leaving

residential institutions. They aim at a maximal reinsertion of persons with a mental

disorder into the society. To some extent there is a specialization by target group

(addiction problems, suicide prevention,…).

The MHC belong to the responsibility of the regional Governments, who can organize

such centres in a perfect autonomy. Each region can decide, by a specific ‘decree’, on

the mission of the centre, and on the necessary conditions to receive an accreditation

or to be subsidized. In the different regions, the functioning of the centres is based on

a multidisciplinary team directed by a specialist in (neuro)-psychiatry. The personnel of

the centres is almost entirely remunerated by the regions. Additional activities under

the federal reimbursement system (NIHDI) are possible, but should remain limited. The

patients pay a very small out-of-pocket contribution for each contact with the centre.

ttt http://www.iwsm.be/institut-wallon-sante-mentale.php?idt=26

uuu Walloon decree 4th April 1986 and M.B 23 rd May 1996

vvv Dutch decree 18 th May 1999 and M.B. 17 th September 1999

www For centers in Brussels depending on the COCOF : decree 27 th April 1995 and M.B. 03 rd October 1995

and centers depending on the COCOM : ordonance 17 th July 1997 and M.B. 22 nd October 1997


92 Evidence Based Mental Health Services KCE reports 144

The mission of the Flemish “centra voor geestelijke gezondheidszorg” (CGGZ) is to

offer adequate care to persons with psychic problems, taking into account the mental

equilibrium of the person and the capacity of the social environment of the patient. The

CGGZ is a second line organization; it has to give priority to persons with severe

and/or persistent problems, persons who have financial and/or social problems, children,

and elderly people. The CGGZ coordinates its actions with the first line and the welfare

institutions; it is also responsible for preventive actions. The CGGZ is responsible for a

geographic area containing minimum 400 000 inhabitants (maximum 26 centres in

Flanders (each centre can have different locations), and 2 in the Flemish speaking part of

the Brussels region). In 2008, 864 FTE professionals were at work in the CGGZ xxx , the

largest part psychologists (247 FTE). This can be explained by the fact that psychologists

in Belgium are not reimbursed in the federal health insurance system (NIHDI). In 2009,

34.967 adults and 3786 elderly persons used the CGGZ yyy , or 635 adult persons

/100.000 population. Taking into account youth (


KCE Reports 144 Evidence Based Mental Health Services 93

A recent evolution of the nomenclature has created specific acts for psychiatric nurses

in charge of controlling the compliance of the patients with respect to the prescribed

treatments.

Among the “mixed” services for ill or handicapped persons not in charge of a hospital

anymore, a coordinating service for care at home exists, funded by the NIHDI: the

GDT (Geïntegreerde dienst voor thuisverzorging) or SISD (Services intégrés

de soins à domicile). This service is open to all types of disorders, and also to

persons with mental disorders. The participation of a general practitioner at the

multidisciplinary concertation is obligatory.

In the Walloon region and the French-speaking and bilingual part of Brussels, there

exists a service aiming to organize and coordinate all types of care and help that

someone suffering from any disease or handicap needs at home, called “Centre de

coordination de soins et de services à domicile” Although this “mixed service” is

often used for elderly persons it is, by decree, open to all ill or handicapped persons in

need of professional help at home.

7.5.5.5 Self-help and non-professional mental health services (10)

Beside the full mental health services and care supply organized by the different

authority levels (federal, community and region), there exist several non-professional

initiatives developed to support persons with a mental disorder and their family. Some

initiatives want to gather the persons with a mental disorder themselves, other aim to

gather volunteers who take care of these persons. Some of them are subsidized by the

regional Governments, and a few also receive subsidies by the Federal public service for

health, food chain safety and environment. Some of the most important self-help and

non-professional mental health services are mentioned below.

Federal organizations

Similes dddd is a Belgian association for all persons with a mental disorder (home, hospital,

different mental care settings) and their family. Besides providing support, it defends the

interests of the patients against the authorities or against practitioners. Among other

specific self-help groups, there exists a Belgian self-help group for persons suffering from

Gilles de la Tourette Syndrome, etc.

Flemish organizations eeee

These organizations are active on the Flemish territory and in Brussels.

Several self-help groups are specific for persons with a mental disorder. Among others,

the organization Ups & Downs ffff is an association for manic-depressive patients and

their family. The patient association UilenSpiegel gggg collects testimonies of psychotic and

schizophrenic patients. The Sarah movement is an independent organization open to

persons with mental disorders confronted with psychosocial problems hhhh . “Zit Stil” and

“Aandacht” iiii are self-help groups for persons with ADHD (attention deficit and

hyperactivity disorder) and their family.

dddd See http://www.similes.org/ (Similes means ‘similar’, the name of the association shows that their

members refuse the distinction between ‘normal’ people and mental patients.

eeee See http://www.ggz-overleg.be/content/ggz/site/5608

ffff See http://www.upsendowns.be/

gggg See http://www.uilenspiegel.net/

hhhh See http://www.sarahbeweging.net/

iiii http://www.adhd-volwassenen.be/index.php?option=com_frontpage&Itemid=1


94 Evidence Based Mental Health Services KCE reports 144

In the Flemish region, there are about different 1 250 ‘zelfhulpgroepen’ jjjj , support

groups organized by patients suffering from all types of diseases which try to ameliorate

their welfare by organizing contacts and activities among each other. They are

supported by “Trefpunt Zelfhulp”, an information and education platform subsidized by

the Flemish Government and the University of Leuven. Eighty-nine of these patient

organizations are regrouped in a Flemish patient platform (Vlaams patiëntenplatform) kkkk ,

which defends the rights and interests of patients. It is also subsidized by the Flemish

Government. Although its activities are not specifically oriented to persons with a

mental disorder, the scope of their actions is large enough to cover psychiatric and

psychological problems. This is also true for the Flemish Knowledge center for

volunteer aid (Vlaams Kenniscentrum mantelzorg) llll

French organizations

These organizations are active on the French territory and in Brussels.

Luss mmmm (Ligue des Usagers des Services de Santé) is a federation of the more than

200 self-help groups and patient organizations existing in Wallonia. Luss aims at

informing them and defending their rights and interests. It is subsidized by the Walloon

region.

Psytoyens nnnn is a Wallonian federation of self-help organizations for persons with a

mental disorder. Specific French-speaking organizations for persons with mental

disorders are, among others, Possible oooo and Reflexions pppp which are self-help groups

for persons with psychotic disorders and schizophrenia. Funambule qqqq is a self-help

group for persons with bipolar disorder and their family. La Graine (see website

Psytoyens) is a self-help group for all persons with psychological or psychiatric

problems. Pasifou (see website Psytoyens) is also a self-help group for all persons with

psychological or psychiatric problems, situated in the Brussels region.

jjjj See http://www.zelfhulp.be/

kkkk See http://www.vlaamspatientenplatform.be/www/index.php

llll See http://www.kenniscentrummantelzorg.be/

mmmm http://www.luss.be/

nnnn http://www.psytoyens.be/

oooo http://www.schizopossible.be/

pppp http://www.asblreflexions.be/

qqqq http://www.funambuleinfo.be/


KCE Reports 144 Evidence Based Mental Health Services 95

7.6 FINANCING OF THE MENTAL HEALTH CARE SECTOR

7.6.1 Global data

In Belgium, 6% of the total health budget of the country is spent on mental health

(Mental health atlas, WHO, 2005) rrrr

7.6.2 Approach per sector of activities

In the following Table, the financing source is mentioned following the ESMS tree if the

data are available.

Table 1: Description of the financing of the different mental health (pure and

mixed) institutions and teams

Services or institutions Financing

Full time hospital care Social security for the fee per day (prix de

journée – verpleegdagprijs) and a personal

intervention per day for the patient in function of

his social status

Part-time hospital care Same financing as for full time hospital care

Mental health centers (MHC) In the ‘centres de santé mentale’, the patients

have to pay an amount out-of-pocket (limited)

corresponding to the received service. The

consultations are free of charge for patients who

do not have sufficient financial resources. A lump

sum personal intervention can be asked to the

patient at the moment of the registration (no

charge for the impecunious patient)

The MHC can charge the patient for non medical

services. ssss

The region gives subsides to the MHC to cover

the personnel expenditures, the functioning costs

and the costs for the first installation. tttt

The centra voor geestelijke gezondheidszorg

receives subsidies from the region.

The ‘centre de santé mentale’ organized by the

COCOF receives subsides to cover the

remuneration of the personal, the general costs

and the variables costs. Each centre receive a

provisional budget which is a maximum subside.

The patients have to pay an intervention

corresponding to the received service or medical

act. The consultations are free of charge for

impecunious patients. The financing and payment

conditions of the centres organized by the

COCOM are similar to those organized by the

COCOF.

Post cure care Same financing as for hospital care

Rehabilitation centers - a yearly budget depending on the maximal

number of services that can be supplied is

determined per centre and divided by the

number of acts. The result leads to a daily lump

sum (“forfeit”) paid by the NIHDI

- services reimbursed by NIHDI, small out-ofpocket

payment for patient

Psychiatric nursing home (PNH) - all the medical acts and services (nurses,

rrrr http://www.who.int/mental_health/evidence/mhatlas05/en/index.html

ssss See decree of 4 th April 1996, chapter V

tttt See decree of 4 th April 1996, chapter VII


96 Evidence Based Mental Health Services KCE reports 144

physiotherapists, rehabilitation, manual therapists,

speech therapists, medical supervision of a

specialist in psychiatry or neuropsychiatry)

executed in a PNH are covered by an

intervention of the sickness fund (mutuality)

- the patient pays an individual intervention equal

to the price for the housing (fixed by the

Minister) reduced by the subsidy of State and the

intervention of the sickness fund

- the patient pays also a daily lump sum (0.95

Euro) to cover the co-payment for reimbursed

and not reimbursed drugs

- the PNH receives a daily intervention of the

sickness fund for maximum 48 days off (holyday)

to promote the social reintegration of the patient

Initiatives of sheltered living uuuu (ISL) A yearly budget is allocated to each ISL, this lump

sum is composed by :

- a unique allocation for the installation of the ISL

- a amount per place for personal costs

- a fixed amount per ISL for the registration of

the Minimum Psychiatric Summary (Résumé

Psychiatrique Minimum) augmented by a fixed

amount per place

- a fixed amount for the medical function

depending on the number of places

- a fixed amount (paid until 2005) for the salary

increase in function of the number of experience

years

- a fixed amount for the organization of daily

activities depending on the number of places (the

financed number of FTE is function of the number

of places)

- a yearly financial compensation for the

measures of career’s end

- the ISL cannot ask a supplement to the patient

or to the mutuality vvvv

7.7 SPECIFIC PROBLEMS OF THE BELGIAN MENTAL HEALTH

ORGANIZATION

• The large part of the Belgian psychiatric cure but also care (e.g. PNH, ISL),

belongs to the domain of the federal Government, and more precisely the

NIHDI. This is remarkable, since this kind of initiatives for other types of

disabled persons, e.g. mentally retarded or physically handicapped persons,

belongs to the responsibility of the regional governments (VAPH or Vlaams

agentschap voor personen met een handicap; AWIPH or Agence wallonne

pour l'intégration des personnes handicapées; DPB or Dienstelle für

Personen mit Behinderung; Brussels COCOF. Probably this situation is the

consequence of the reconversion operations that took place in the nineties

and the first years of this century. This does not mean that the services

provided for persons with mental disorders are inappropriate, but one should

be careful because the NIHDI does not have the same experiences and

background in the organization of services meant for life-long care and

support.

uuuu A.R. 18 th July 2001 (MB 26 th September 2001) modified by A.R. 29 th September 2002 (MB 07 th November

2002), A.R. 10 th March 2003 (MB 02 nd April 2003) and A.R. 13 th March 2003 (MB 20 th March 2006)


KCE Reports 144 Evidence Based Mental Health Services 97

• One group of persons with a mental disorder however, fall under the

responsibility of regional governments: persons with autism-spectrumdisorders,

probably because they are considered to be “developmental

disorders” and because their signs and symptoms become clear early in life.

A group for which it is less clear where they can find long-term care, is the

group of persons with Acquired brain injuries.

• Psychiatric cure (diagnosis and treatment) is still mainly concentrated in

« Psychiatric hospitals » (4686 A-beds) rather than in psychiatric departments

of general hospitals (2404 A-beds).

• For PNH and ISL, the norms decided on by law are not yet reached. Yet

there are long waiting lists to enter. New initiatives might be necessary to fill

the gap.

• For day activities of those persons living in ISL or on their own, but not

capable of working any more, the « day hospitals » are probably too much

oriented towards treatment. There exist some day centers (activity centers)

reimbursed by the NIHDI, are these initiatives sufficient for the target

population ?

• Specific structurally reimbursed services for this population to support work

rehabilitation (supported reinsertion into work) were not found, do they

exist ? Can this population rely on general initiatives, e.g. by Public Welfare

Centres (CPAS) or general federal initiatives (VDAB etc)?

• Concerning the third reformation wave, some coordination functions are

already structurally implemented and reimbursed : the Concertation

platforms, the « Institut Wallon de santé mentale », and recently the Walloon

« Centres de référence de santé mental » for coordination of SSM and

ambulatory mental health care. It might be useful to delineate more into

detail the actions of these different initiatives, to prevent overlap. To improve

the working, and to evaluate the strong and weak point of this type of

initiatives, it might be useful to install external evaluations, e.g. every 5 years.

• Initiatives for patient centred coordination still only exist on a temporay basis

(the different types of Projects), and still have to prove their added value.

Once installed, a system of evaluation of their working should also be

foreseen.

• For the Psychiatric hospitals, Psychiatric departments of general hospitals,

PNH and ISL, data registration is obligatory (the MPD). The Belgian MPD are

very extensive, and include a lot of information, e.g. not only on psychiatric

diagnosis but also on functioning of the included persons. It is worthwhile to

analyze these data and publish this kind of studies.


98 Evidence Based Mental Health Services KCE reports 144

8 FRANCE

8.1 LITERATURE SEARCH: METHODOLOGY

Search on the web (Google and OAister) (search terms: ‘Organisation of psychiatry in

France’, ‘Financing of psychiatry in France’, ‘Mental health organisation in France’,

‘Mental health financing in France’), search on sites of DREES (Direction de la

Recherche, des Etudes, de l’Evaluation et des Statistiques) IRDES (Institut de

Recherches et de Documentation en Economie de la Santé), French Health Ministry,

WHO (World Health Organisation), OECD (Organisation for Economic and

Cooperation and Development), CNAMTS (Caisse Nationale d’assurance Maladie des

Travailleurs Salariés), INED (Institut National d’Etudes Démographiques), INSEE,

UNCPSY (Union Nationale des Cliniques Psychiatriques privées), Social Security, HAS

(Haute Autorité de la Santé), MNASM (Mission Nationale d’Appui en santé Mentale -

http://www.mnasm.com/ ), specific web addresses : http://www.annuairesante.com ;

http://www.cadredesante.com ; http://legifrance.gouv.fr ; http://archives.handicap.gouv.fr;

http://www.anaes.fr ;Direction Générale de l’Action Sociale (DGAS)

http://www.serpsy.org;http://www.cohesionsociale.gouv.fr/; Haute Autorité de lutte

contre les Discriminations et pour l’Egalité http://www.halde.fr.

No information (references, data…) has been included after August 31, 2009.

8.2 ORGANIZATION AND FINANCING OF THE HEALTH

CARE SECTOR: SOME ASPECTS

In 2007, France had 63,6 million inhabitants wwww . We can distinguish xxxx two kinds of

health care costs covering: the statutory insurance system, composed by four

different schemes (employees and their families – self-employed workers – agricultural

workers and their families – others), and the complementary insurance system,

divided into three types of institutions (mutualities – private companies – provident

societies).

8.2.1 The statutory insurance system

Each year since 1996, the parliament passed an Act on Social Security Funding (LFSS) yyyy

based on the reports of the Accounts commission (Cour des Comptes) and the

National Health conference. This act sets, among other things, a projected target for

health insurance spending for the following year known as the national ceiling for health

insurance expenditure (ONDAM) zzzz . This global target is composed by four specific

budgets for the public hospital sector, the private hospital sector, the ambulatory care

(soins de ville) and the medical – social institutions.

Table 8.1: Composition of the National budget for health care in 2007

ONDAM 2006 Mil € % of total budget % of the GDP

Ambulatory cares 66,7 47,3% 3,7%

Total hospital cares 63,4 44,9% 3,5%

Medical - social institutions 11,0 7,8% 0,6%

Total 141,1 100,0% 7,9%

GDP 1 792,0

Source: Report on Social Security 182 and INSEE

wwww http://www.insee.fr/fr/themes/tableau.asp?reg_id=0&ref_id=NATnon02151

xxxx We base this section on three main sources Sauvignet 2004 180 and Sandier et al, 2004 181 and the reports

of the Social security (Comptes de la sécurité sociale). We use different official sources of data to

compute proportion of beneficiaries and the composition of the financing.

yyyy LFSS for Loi de Financement de la Sécurité Sociale

zzzz ONDAM for ‘Objectif National des Dépenses de l'Assurance Maladie’


KCE Reports 144 Evidence Based Mental Health Services 99

The statutory health insurance system is divided into three main health insurance

schemes and a set of 12 special schemes for certain categories of the population.

8.2.1.1 The general scheme

The general scheme originally included 129 (this figure is currently being cut down, because

of ongoing restructuring) local funds (CPAM) aaaaa to affiliate members and reimburse the

major part of the cost paid by the patients, 16 regional funds and a national fund

(CNAMTS) bbbbb . About 81 % of the total population is covered by this scheme. ccccc

Table 8.2: Breakdown of the financing of the general scheme in 2007

General scheme Billions € % of the total

Contributions 65,0 51,0%

CSG 49,0 38,4%

Taxes 13,5 10,6%

Total 127,5 100,0%

% of the total population 81,2%

Source: Les comptes de la sécurité sociale – Septembre 2007 – INED (Institut National d’Etudes

Démographiques)

8.2.1.2 The other schemes

Two other schemes – the self-employed scheme and the farmers and agricultural

employees scheme cover respectively 5% and 7% of the population. Other smaller

schemes, generally based on professional specificities and set up for historical reasons

still cover approximately 7% of the population (all together).

8.2.2 The complementary insurance system

The complementary coverage is provided by three types of OCAM ddddd organizations:

the mutual insurance associations, the private for-profit insurance companies and the

provident institutions. We distinguish 740 OCAM composed by 550 mutualities, 130

private insurers and 60 provident institutions. In 2002, 86 % of the population was

covered by a complementary insurance and if we take the CMU – C into account (freecomplementary

coverage for underprivileged people), the covering concerned 91 % of

the population 180 .

8.2.3 The financing of the hospital sector

Since 2006, all the public and private health institutions, earlier financed by a global

budget eeeee , have to present an estimated state of incomes and expenses. This new

budget system is linked 182, 183 with the new system of price fixing (T2A) fffff .To implement

this new system of price fixing, homogeneous groups of patients are required to

compute predicted costs per group. Nevertheless, the determination of such costs is

more difficult to implement for care such as psychiatry. That is the reason why the

psychiatric institutions are yet financed by a global budget, waiting for a validation of a

T2A modelling.

aaaaa CPAM for Caisses Primaires d’Assurance Maladie

bbbbb CNAMTS for Caisse Nationale d’Assurance Maladie des Travailleurs Salariés

ccccc We computed the proportion of beneficiaries using the total population (61 538 thousand in 2007). This

means that the denominator of the proportion contains the total number of state employees (4 % of the

total population) and the total number of the beneficiaries of the three main insurance schemes and the

twelve special schemes.

ddddd OCAM for Organismes d’Assurance Maladie Complémentaires (Complementary Health Care Insurance

Institutions)

eeeee Dotation globale

fffff T2A = Tarification à l’activité


100 Evidence Based Mental Health Services KCE reports 144

8.2.4 The French health care system: which problems?

8.2.4.1 A lack of coordination and continuity of care.

In spite of its advantages (especially freedom of choice for patients and a relatively high

average density of health care supply, at least in most populated areas), the main

weaknesses of the French system remain the lack of coordination and continuity of care

provided by often isolated professionals, as underlined by the HIT report issued in

2004 184 . This is not specific to ambulatory medicine (GP and specialized doctors alike)

but also to the interface between the ambulatory sector and the hospital sector. In

practice information sharing and more generally coordination between both sectors

remain poor and problematic.

This trait of the French system is specifically penalizing for chronic patients, who require

a long-lasting medical follow-up over several years (or even a lifelong follow-up). As a

matter of example, a national survey conducted on diabetes showed that only 40% of

diabetic patients have an eye examination yearly (in line with the official guidelines on

diabetes). This kind of statement can be applied to chronic diseases in general, including

psychiatric ones.

8.2.4.2 Networks and the GP gate-keeper system: solution or not?

Since the nineties, health authorities have set up reforms and innovative projects to

tackle this problem and to try to bridge the gap between both sectors (and more

generally to improve coordination of care and patient-centred approach).

1. On a purely voluntary basis health care networks have been implemented at a

local level since 1996 and supported by the National Health Insurance Funds.

These networks were set up with a view to improving coordination of care and

avoiding redundant exams and/or waste of working time, especially for chronic

diseases. However, these networks have reached their limits: they are based on

purely voluntary basis and this kind of health-care organization is not the norm

(legally speaking).

2. GP-steered gate-keeper systems.

a. The first system – called “Médecin Référent” (litt. Referring Physician) was

set up on a purely voluntary basis. Few GPs joint this system (ca 10%), and

eventually it did not prove very efficient on the long term.

b. The second system – called “Médecin Traitant” (litt. Treating Physician) was

organized on a compulsory and regulatory basis (Health Care Modernization

Act 13 August 2004). All patients are required to chose a GP as gate-keeper

to enjoy normal rate of reimbursement. However this system is partly bypassed

in the field of psychiatric care: direct access to psychiatric care

specialists is allowed for patients below 25. Conversely, as shown below,

referral to secondary care is not always well organized, basically because of

supply shortage in many regions.

8.2.5 Impact of quality assessment in the French health care system.

The French National Authority for Health (HAS or Haute Autorité de Santé) was set up

by the French government in August 2004 ggggg in order to bring together under a single

umbrella a wide range of activities designed to improve the quality of patient care and

to guarantee equity within the healthcare system. Therefore, activities of the HAS range

from publication of guidelines to accreditation of healthcare organisations and

certification of doctors.

In France, quality control is broken down into 3 different proceedings:

Certification process for health care establishments hhhhh (since 2004 the word

Certification has superseded the word “accreditation” for health care establishments)

ggggg http://www.has-sante.fr/portail/plugins/ModuleXitiKLEE/types/FileDocument/doXiti.jsp?id=c_885249

hhhhh http://www.has-sante.fr/portail/


KCE Reports 144 Evidence Based Mental Health Services 101

Evaluation of Professional Practices (EPP)

In the very last version of the accreditation manual (2010 Version), specific criteria in

the domain of EPP are defined that apply to psychiatric practice – Criteria 19c “Suicidal

risk” and Criteria 19 d “Hospitalization without consent” (patients sectioned pursuant to

the French legislation – Act dated 27 June 1990 modified by Psychiatric patients’ rights

of 4 March 2002).

Accreditation of doctors for “at-risk specialities”. However, psychiatry is not concerned

by this latter type of quality control.

The final decision of the HAS is completed by a specific list of follow-up decisions,

designed to ensure a concrete implementation of improvement measures. However, we

must bear in mind that :

• There is no individual “grading” of doctors, health professionals, or

hospitals

• There is no direct connection between the accreditation process and

funding channels (responsibility of the Regional Hospital Agency).

Further administrative decisions can be made against hospital

experiencing major problems, but this remains within the remit of the

Regional Hospital Agency only.

• This accreditation process is mainly focused on a cross-functional

approach, work processes, safety measures and not on quality of

medical acts individually.

Key points

• The French health care system remains problematic in terms of

coordination of care, interface between primary and secondary care and

more generally continuity and follow-up.

• The French quality assessment system has not been designed as a

cost/efficiency measurement framework.

8.3 THE MEDICAL SOCIAL SECTOR IN FRANCE

We mention some characteristics of this sector because it finances a part of actions

considering persons experiencing problems caused by the lack of autonomy. After the

heat wave of august 2003, the authorities decide to organize a central response to the

specific problems caused by the lack of autonomy. The Caisse nationale de solidarité

pour l’autonomie (CNSA) was created by the law N°2004-626, 30th june 2004. One of

its missions is the repartition of the credits defined by the ONDAM and destined to the

old dependent people and the handicapped persons. The CNSA received its first

complete budget in 2006 and since, the ‘objectif global des dépenses’ (Global budget for

the expenses) is the combination of two principal sources: the credits of the medicosocial

ONDAM and the own revenues of the CNSA.

Table 8.3: Revenues of the Caisse Nationale de Solidarité pour l’Autonomie

(CNSA) (Total 16,2 Milliard euros) – Budget 2008

Own revenues Credits from the health insurance (medico-social

Contribution Solidarité Autonomie : 2,289

Contribution Sociale Généralisée : 1,095

Participation ‘retirement system’ : 0,065

ONDAM)

Health insurance old and handicapped persons :

12,781

Source: Budget 2005 and 2006 of the CNSA185 and Budget of Social security 182, 183


102 Evidence Based Mental Health Services KCE reports 144

8.4 ORGANIZATION OF THE MENTAL HEALTH CARE

SECTOR IN FRANCE

We focus our analysis on the general psychiatry for adults. This means that we do not

take into account neither child and adolescent psychiatry nor forensic psychiatry.

8.4.1 Historical background iiiii

It is common knowledge that the history of the mental health in France is linked to the

movement of the ideas and realizations in the rest of the world. But we only sketch

here the most important moments of the French history. We begin this history in 1802

with the permanent closure of the ‘salles de fous ou de folie’ and the creation of the

lunatic asylum (asiles d’aliénés) where the mental patients were taken in charge by an

alienist. The law of June 30 th 1838 remained the institutional framework for the

management of mental patients during 150 years. This law organizes the hospitalization

in the public and private institutions, the protection of the sick persons and of theirs

goods. The principal aims of this law were the organization of asylum, the protection of

the population and the regulation of the compulsory admission. In 1922, the creation of

the first open hospital by Doctor Rousselle is the first step of the transformation of the

asylum into a hospital. By the decree (circulaires) of October 13 th 1937 and September

2 nd 1946, the lunatic asylum becomes the psychiatric hospital.

Since the sixties, key trends of organization of mental health policy have been the

following:

• From a clinical point of view, “de-institutionalization”: patient management

outside hospital environment as long as the patient’s condition enables it,

with a view to safeguarding his dignity. This policy was largely inspired by

WHO recommendations.

• From an administrative point of view: a long-term “sectorization” policy,

ie. a division of the territory into “sectors” (health care supply areas), with a

view to cover a specific part of the population and to set up multidisciplinary

teams providing preventive care, acute treatment and follow-up. At the

present time, the French territory is divided into ca 800 sectors (general

psychiatric care/ patients above 20 years of age).

Following Lucien Bonnafé jjjjj , the official birth of the sectorization is the colloquium of

Sèvres in 1958 organized by the céméa kkkkk . The decrees (Circulaires) of March 15 th

1960 and March 14 th 1972 give the legal base of this radical transformation of the mental

health care, which should make the mental health sector evolve from a ‘hospitalcentrism’

to an open and community system.

However, the basic principles of the French mental health care “sectorization” policy

are somewhat different from the basic organizational principles in many other countries,

and specific traits of the French policy have been identified as below:

• It did not involve the closure of a large number of psychiatric hospitals (like in

the UK or in Italy) because a comprehensive patient management including

hospital and ambulatory care has been deliberately favoured.

• Efforts have been made to anchor the initial step of the patient pathway and

patient management as close to his place of residence as possible.

In short, from the beginning onwards, the “sectorization” has never been considered to

be an alternative to the hospital; it has been considered to be a complementary activity.

Whether this has been realized or not, will be discussed below.

iiiii We based this historic part on http://www.ch-charcot56.fr/histoire/histpsy/7cadregl.htm,

http://psychiatrie.histoire.free.fr/index.htm, http://www.serpsy.org/histoire/histoire_index.html, Chapireau,

2007, pp. 127-143 186

jjjjj French Psychiatrist 1912 – 2003. He has initiated and participated to the sectorization in France

kkkkk Céméa : centres d’entraînement aux methods d’éducation active


KCE Reports 144 Evidence Based Mental Health Services 103

The law of December 31 st 1985 legalizes the fusion of the hospitalization expenses with

the sector expenses and reinforces the decree (Circulaire) of 1960. The decree

(Décret) of March 14 th 1986 defines the technical organization, the nature and the

responsibility of the public institutions of care, making the difference between

institutions with and without residential possibilities. The evolution of the

deinstitutionalization has also to be analyzed taking into account the development of

elderly care and care for handicapped persons, the development of the social assistance

and, partially, the development of the drugs for mental problems.

8.4.2 General principles – the sectorization

The sector is based on a multidisciplinary team and different possibilities of residential

and ambulatory, medical and social services. Each sector is responsible for the

accessibility and the continuity of the care for every patient in each stage of the

development of the disease. The organization of psychiatry and mental health care is

defined by the SROS lllll (Schéma Régional d’Organisation Sanitaire – Regional Scheme of

Sanitary Organization). The regional scheme of the psychiatric hospital organization is

defined by the Regional Agency for hospitalization (ARH – Agence Régionale

d’hospitalisation).

Of all patients treated in 2003 in the “sectorized” psychiatry 0,5% were children (


104 Evidence Based Mental Health Services KCE reports 144

In 2003, the multidisciplinary teams have seen approximately an average of 1 500

patients treated by medical (6.5 FTE) and non-medical (78.2 FTE) personnel 187-189 . For

the same year, we find 55 % of the sectors attached to a public health institution

specialized in psychiatry (former specialized hospital centres), 37% attached to a non

specialized public health institution (hospital centre or regional hospital centre) and 8%

attached to a private specialized health institution.

8.4.2.2 General organization of the hospital activities

The distribution of residential beds is clearly uneven throughout the country 191 (see also

paragraph 8.4.3.3). Moreover, a low density of beds is not necessarily compensated by a

high density of places (i.e. partial hospitalization during day or night only). The number

of adult beds available in 2004 was about 56.700, or 91.4 per 100.000 inhabitants 193 but

with a wide range, depending on the area 190 . The number of adult partial hospitalization

places equalled 17.666, or about 28.5 per 100.000 inhabitants 193 . In 2000, two thirds of

all the available beds were located in mental hospitals, one third in general hospitals 190 .

Also the repartition of psychiatrists is very uneven (see 8.4.3.3 and Appendix); in 2004

there were on average 23 psychiatrists for 100 000 inhabitants, but with a large

difference between sectors and departments 190 .

From a point of view of financing, we can distinguish two budgeting systems. First, the

system of projected budget (budget prévisionnel) applied to the public institutions and

the private institutions which have chosen the same price fixing system as the public

institutions (system of global budget). Second, the OQN (Objectif Quantifié National)

or National Quantified Goal applied to the pure private institutions. In the first

category, we find the CHS (Centres Hospitaliers Publics Spécialisés en Psychiatrie), the

SPHG (Services de Psychiatrie des Hôpitaux Généraux Publics) and the HPP (Hôpitaux

Psychiatriques Privés Faisant Fonction Publics). As shown in Table 8.4, the ‘pure’ public

institutions represented in 2004 2/3 of the beds and 4/5 of the places ooooo . Taking the

private institutions under global budget into account, the ‘public’ sector represents 80 %

of the beds and 98,5 % the places in 2004. The second category is composed by pure

private institutions or clinics, and post-cure houses. 194 195 . To further complicate the

matter, whereas the system of geographical “sectorisation” is specifically meant to

organize psychiatric care, some public general hospitals and most but not all private

specialized hospitals also provide hospital services to persons with mental disorders

(Coldefy 2007 p 61) outside this “sectorized” system (see Table 8.4).

Table 8.4: Number of beds (hospitalization) and places (partial

hospitalization) in the sectorized and not sectorized psychiatry for adults in

France (situation on 31 December 2004)

Private

institutions

financed by global

budget

Private

institutions

outside global

budget

Adult Public

Total of the

psychiatry institutions

institutions

Beds Places Beds Places Beds Places Beds Places

Sectorized 37.718 14.104 5.354 1.728 0 0 43.072 15.832

Not sectorized 1.022 302 1.544 1.310 11.081 222 13.647 1.834

Total 38.740 14.406 6.898 3.038 11.081 222 56.719 17.666

Source : Chaleix 2006 p. 65 193

ooooo We use the concept of ‘bed’ for complete hospitalisation and ‘place’ for partial hospitalisation (night or

day)


KCE Reports 144 Evidence Based Mental Health Services 105

8.4.2.3 The development of ‘inter-sectoriality’

The common pooling of means and personnel between sectors becomes more and

more necessary to meet specific problems of psychiatric patients. These collaborations

can take two forms: a non-formalized inter-sector collaboration where one physician is

responsible for the delivery of acts for several sectors (in 36% of the sectors in 2003).

The formalized collaboration is organized by the means of an autonomous team which

delivers services for several sectors (50% of the sectors in 2003 with an average of 2 or

3 teams per sector) (Coldefy, 2007, pp; 41-44 187-189 ).

8.4.3 Evolution of the French policy from 2003 onwards

8.4.3.1 The Cléry-Mélin Report

In 2003, the Clery-Melin Report, titled “Action plan for development of psychiatry and

promotion of mental health in France” 196 became a key milestone for decision-makers. This

report outlined the many pitfalls and problems encountered by the French mental

health care system, and formulated proposals for improvement. The 7 priorities, as

identified by this report were the following:

1. Reorganising first line health care supply and raising public’s awareness on mental

health-related issues

2. Reducing inequality in health care & health care supply

3. Improving child and teenager mental health care

4. Setting up a specific framework for the elderly

5. Recasting of judicial legislation

6. Improving quality assessment and training of health professionals

7. Supporting research activities

8.4.3.2 The Mental Health Plan 2005-2008: Last reform of the sector in France

Following the Clery-Melin report mentioned above, the Mental Health Plan 2005 –

2008 (1.5 billion €) 197 was implemented by the Dpt of Health, more precisely, based

on the five following priorities ppppp :

• Decompartmentalizing patient management: improving information and

prevention, improving coordination between GPs and other professionals,

improving geographical distribution of health professionals, and continuity of

patient management.

• Better consideration of patients’, carers’ and health professionals’ problems

and recruitment plan.

• Providing further support to research and quality assessment activities:

building up and sharing knowledge on best practices, improving information

on psychiatry.

• Implementing disease-centered and population-focused programs:

depression/suicide; judicial programs, youngsters, vulnerable groups.

• Practical follow-up and assessment of the plan.

The Department of Health conducted in 2006 an assessment of the situation and

underlined the following achievements of the Mental Health Plan for 2005-2008:

• As a whole, a major supplementary financial involvement: 1.5 billion € as

underlined above (which would correspond to 250 mil € for Belgium).

• An ambitious extra-recruitment plan: 275 specialized doctors, and 2250

paramedics, psychologists, and other professionals. Hence, the number of

psychiatrists should be stabilized until 2030.

ppppp Description of the plan in LOPEZ 2006 198 and three first editions of the ‘La Lettre du Plan Psychiatrie et

santé mentale’


106 Evidence Based Mental Health Services KCE reports 144

• An improvement of the psycho-social care supply. Notwithstanding this,

the situation remains difficult: 20% of psychiatric beds are allocated to

patients not in need of hospital care (anymore), but to whom supportive

community medico-social care is not available. This is clearly due to the fact

that no financial continuity is guaranteed between the upstream clinical

process of the patient pathway – ie. the initial clinical dimension of the patient

pathway- and the medico-social dimension of the patient management (see

also further paragraph 8.5.3.1). This lack of financial continuity is due to the

diversity of funding origins. In practice, medico-social care is funded by local

authorities, and actual level of funding depends on their actual financial

capacity. Therefore, there is no guarantee that this funding meets the

patient’s needs.

• A new “population-centred” approach to focus on the most vulnerable

patients (elderly people, youngsters, people subject to suicidal behaviours,

etc..).

• Implementing pathology-centred and population-centred approach for the

new programs (depression, suicide, elderly people, social outcasts..).

• Fostering decompartmentalizing of patient management: improving

coordination of health care suppliers, patient-centred approach, and multidisciplinary

team work.

8.4.3.3 Situation anno 2009: still many drawbacks.

Rapport Couty (Jan 2009)

In January 2009, a survey was issued on the request of the Department of Health, to get

a comprehensive view of the mission and the organization of mental health and

psychiatric care in France. This survey, also known as “Rapport Couty” 199 made specific

suggestions on the following aspects: training, research, and coordination of care at the

local level. To realize the latter aspect, the rapport Couty launched an innovative idea:

the implementation of Mental health local cooperation groups (Groupement local de

coordination). These Groups should bring together all types of professionals in charge

of first line mental health care, be it prevention, residential community care, ambulatory

care, social care,… but excluding hospitalization. The task of these groups would be to

provide all types of care necessary in their region, and to ascertain 24h access to the

services. It is worth mentioning that the last reform on health care organization

designed by HPST (Hôpital patients santé territories) Act of July 2009 enables new

cooperation frameworks and delegation models between health professionals under the

control of the HAS. This could also be an opportunity to improve field organization of

mental health care.

Rapport Milon (April 2009)

In April 2009, MP Alain Milon issued a new and comprehensive report on the French

situation in the field of psychiatric care, including the image of psychiatry and psychiatric

care in France: “La psychiatrie en France: de la stigmatisation à la medicine de pointe” 200 .

He conducted a survey on current organization and practices and put forward

proposals for the forthcoming years. He underlined the drawbacks of the current

French system, and the numerous obstacles that patients encounter or experience along

their pathway.

The first major problem outlined by Milon, is the persisting problem of uneven

distribution of health care supply and actual access to health care (already

mentioned in the Cléry-Melin Report 2003). Distribution of psychiatric care supply

across France is quite comparable to what it is for other medical fields, i.e. an uneven

distribution between regions, between urban and rural areas, and between privileged

and underprivileged areas. E.g., in 2008 the number of practising psychiatrists was 11

271. Forty-seven % of them was working in the ambulatory sector, and 53 % in hospitals

(or clinics), which can be considered as a good balance between both sectors.


KCE Reports 144 Evidence Based Mental Health Services 107

However, 5267 psychiatrists or half of the total workforce was located in the Parisian

region and in five southern large cities, although their population amount to only 30% of

the overall French population (See Appendix). Following the measures of the last Mental

Health Plan 2005-2008, the overall number of psychiatrists should be stabilized by 2030,

but this will not resolve the problem of distribution itself. The latter problem is unlikely

to be solved over the next years, as it also deals with freedom of establishment of

physicians in general.

A second point outlined by Milon, is the problem of the waiting times, which in most

public hospitals can reach several months. This problem has also been mentioned by

Coldefy et al 187-189 . Milon cites an in depth survey conducted recently by the French

National Authority for Health (Haute Autorité de Santé or HAS), on the issue of

waiting times in public hospitals (Psychiatric Departments). This survey has analyzed the

consequences of this phenomenon. Indeed, combined with other factors (especially

poor distribution of supply across regions) it has far reaching negative consequences for

French patients. It has been clearly noted by the HAS that one third of schizophrenic

patients, one half of depressed patients, and three quarters of alcohol-addicted patients

do not have access to affordable health care in due time. In practice the GP is often in

charge of long-term follow-up of chronic patients. According to Milon, a noticeable part

of psychotherapeutic tasks and consultations are carried out by psychiatrists, although

they are - or at least could be considered as - a matter for psychology (and not

psychiatry). However, psychologists are not reimbursed. This problem has been

identified in different countries.

A third point, according to Milon, has to do with training of health professionals.

On the whole health care supply chain, one must outline, that health professionals’

actual skills do not always meet the required standards. In that respect the most urgent

problems seem to be the following: 1. GPs: in spite of their key role in early detection

of psychiatric patients as well as in long-term follow-up, GPs’ training is not specifically

dealing with psychiatric issues; 2. Nurses: following a regulatory reform, the degree of

psychiatric nurse officially disappeared in 1992 (unlike in other countries). Graduated

psychiatric nurses continued to work in public hospitals only and psychiatric nursing

care cannot be provided in an ambulatory environment. There is currently a large

consensus to solve this regulatory problem and to recreate a specific degree of

psychiatric nurse care (Master’s degree) over the next years.

The fourth point outlined by Milon, deals with collaboration issues between

professionals. Due to a lack of fitting structures or regulatory framework,

collaboration between professionals – ie GPs and secondary care; nurses and physicians;

health professionals and other professionals; ambulatory sector and hospital sector –

remain difficult or at least uncertain. As already pointed out in paragraph X.2.4, this

holds true not only for the mental health care sector, but throughout the full health

care sector. Two possible solutions have been implemented since the nineties to tackle

this general problem of lack of coordination and cooperation: 1. health care networks

(set up on a purely voluntary basis) are supported by the National Insurance Funds.

However, in 2008 only 32 mental health care networks had been established, most of

them situated in 15 of the +-800 sectors (Rapport Milon 2009, p68); 2. another type of

collaboration between different service providers are “Conventions”, or written

agreements between a psychiatric sector and e.g. social care providers (Coldefy 2007

p44). However, not much information has been found on practical consequences of

these Conventions; 2. a compulsory GP-steered gate-keeper system exists (see also

paragraph 8.2.4.2). Nevertheless, these measures seem far from sufficient to improve

substantially the situation, which is even more difficult in areas experiencing health care

supply deficiency.


108 Evidence Based Mental Health Services KCE reports 144

The IRDES report (August 2009)

In August 2009, an in-depth and retrospective analysis of the 50-year sectorization

policy, carried out by the IRDES “Questions de Santé N. 145 – August 2009”, has

clearly identified several weaknesses and limits in this field (see also Coldefy 2009) 201 .

From a conceptual point of view, sectorization does not involve a uniform mental health

policy and a common way of delivering care across the country. This can be justified

from a practical point of view. However, it can be difficult in terms of visibility but also

quality level.

In terms of full-time and part-time hospital beds, the level of health care supply

remains uneven across regions, as already discussed in paragraph 8.4.2.2. Likewise,

distribution of medical and nursing workforce remains clearly uneven across regions

(see also paragraph 8.4.3.1, Cléry-Melin Report; and 8.4.3.3, Rapport Milon) and the

problem of discrepancy between some urban and some rural areas has not been solved

so far. In other words, the sectorization policy did not always succeed in covering a

reliable interface between hospital-centred strategy and ambulatory alternatives. This is

clearly illustrated by the results of the survey conducted by the IRDES.

Based on this survey the IRDES has sorted psychiatric sectors by “level of resources”;

and geographical dimension, i.e. rural or urban environment has been taken into

account. Resources must be understood as the wide range of criteria including: full time

and part-time beds, full-time equivalent health professionals, timeslot and accessibility of

psychiatric care. As clearly shown on the map in the Appendix, discrepancies exist

across regions but also within each region, often without clear explanation, other than

historical ones. As already mentioned, patients in some rural areas enjoy rapid access to

high-level psychiatric care, whereas others do not.

Key points

• The recent evolution of the French policy has focused on

decompartmentalizing and care coordination, pathology- and populationcentred

approach, an extra work force recruitment plan and improvement

of socio-medical care supply.

• However, limits and weaknesses have been identified: long waiting lists exist,

actual access to adequate care remains problematic for a noticeable part of

patients, distribution of health care supply remains uneven and coordination

between primary and secondary care is poor.

8.4.4 Mapping of existing services: Introduction

We use the ‘Service Tree’ developed by Johnson et al. to map the mental health

services 5 . This ‘Tree’ distinguishes five main different structures of mental health

services: secure, residential, day & structured activity, out-patient & community and selfhelp

& non professional services. The second, third and fourth structures are

developed as a tree to take into account the differences between acute and non-acute

care, emergency and continuing care but also the duration, the intensity and the

mobility of the care or activities.

We present a table of all the existing services applying the ESMS tree and we describe

the organizational and financial aspects of each of them in the following sections. We

distinguish ‘Full mental health services’ which is a matter for the psychiatric sector,

from the Mixed services (‘Residential mixed services’ and ‘Mixed support teams’). We

find ‘full mental health services’ in all the categories of the Service Tree developed by

Johnson but the mixed services are typically residential services and mixed teams are

only ambulatory services. Residential mixed health services and mixed support health

and social teams concern a broader group of patients or persons knowing social

problems. Therefore, we propose three exhaustive lists of services; each list is ordered

according to the ESMS tree (the figures in brackets refer to the synthetic Table).


KCE Reports 144 Evidence Based Mental Health Services 109

Table: Synthetic presentation of the ESMS tree

SECURE (1)

RESIDENTIAL Generic acute Hospital (2)

Non-hospital (3)

Non-acute Hospital (4) Time limited (4.1)

Indefinite stay (4.2)

Non-hospital (5) Time limited (5.1)

Indefinite stay (5.2)

DAY & STRUCTURED Acute (6)

ACTIVITY

Non-acute (7) High intensity (7.1)

Low intensity (7.2)

OUT-PATIENT & Emergency care (8) Mobile (8.1)

COMMUNITY

Non-mobile (8.2)

Continuing care (9) Mobile (9.1)

Non-mobile (9.2)

SELF-CARE & NON-PROFESSIONAL (10)

8.4.4.1 The ‘full mental health’ services

We name ‘full mental health services’ all the services organized in the context of the

sectorization of the adult psychiatry. Hospitalization beds (full time) and places (part

time) in the non-sectorized psychiatry (see Table 8.4) are also mentioned: they amount

to 24% and 10% respectively of the total 193 . We did not find any information on the

availability in the non-sectorized psychiatry of: residential non-acute non-hospital services,

non-hospital services for day and structured activity, or outpatient and community care;

so these services might be underestimated.

The evolution of the structures per sector is described in Table 8.5. The CMP are the

most representative services in the psychiatric sectors. All the sectors, except 4, have

organized a CMP and in 70 % of the cases we find 2 CMP 187-189 . In 2003, there were 817

sectors in France, and 2070 CMP. We will describe all of these services in the following

pages.

Table 8.5: Evolution of the structure of care in all the sectors

1989 1993 1997 2000 2003

CMP (5 days or +) 83 89 93 97 98

CMP (- of 5 days) 54 50 45 45 42

Day hospital 80 82 83 83 84

CATTP 41 59 69 78 84

Night hospital 63 69 61 59 55

Associative appartment 46 52 53 53 52

Accueil familial thérapeutique 32 39 44 34 35

Appartement thérapeutique 14 20 20 21 22

Atelier thérapeutique 26 19 14 14 12

Centre de post-cure 11 8 9 7 6

Centre d’accueil permanent 7 10 8 4 3

Unite d’hospitalisation à domicile 4 6 5 5 5

Centre de crise 3 6 5 4 3

Full time Hospitalization ND 98 98 98 96

Source: Coldefy 2007 187-189 based on the activity reports of the psychiatry sectors, DREES

Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques– How to read this table:

in 1989, 83 % of the sectors had a CMP open during 5 days or more. In 2003, there were 817

sectors in France.


110 Evidence Based Mental Health Services KCE reports 144

The ‘full mental health services’ can be classified according to the ESMS tree (the figures

refer to the synthetic table):

• Hôpital Temps Plein (Complete hospitalisation): 4

• Hôpital de Nuit (Night Hospital) : 4

• Accueil Familial Thérapeutique (Therapeutic Family) : 5.2

• Centre de Postcure : 5.1

• Appartement Thérapeutique (Therapeutic Apartment) : 5.1

• Associative apartment : 5.1 (see also “residential mixed services”)

• Services d’Hospitalisation à Domicile (HAD) (Home Hospitalisation) : 5.2

• Centre d’Accueil Thérapeutique à Temps Partiel (CATTP) : 7

• Hôpital de Jour (Day hospital) : 7

• Atelier Thérapeutique (Therapeutic Workplace) : 7

• Centre d’Accueil Permanent (CAP) : 3 & 8.1 & 8.2

• Centre de Crise (Crisis Centre) : 3 & 8.2

• Centre Médical Psychologique (CMP) : 8.1 & 8.2 & 9.1 & 9.2

• Psychiatrist : 9.2

• Psychologist : 9.2

• Psychoanalyst : 9.2

8.4.4.2 The ‘residential mixed’ services (5.1 & 5.2)

The second list is composed by residential services qqqqq which propose a shelter for

persons who have lost the basic social references like house, job but also physical and

mental health. These services are not specifically dedicated to mental patients but can

also be used by persons with mental problems 202 .

Many psychiatric sectors signed “Conventions”, or written agreements with “mixed

services” e.g. medical-social or social care providers (Coldefy 2007 p44), to enhance

collaboration between different service providers. However, not much information has

been found on practical consequences of these Conventions.

As indicated below, the residential mixed services all belong to the ESMS category

“residential non-acute non-hospital” (the figures refer to the ESMS tree in the synthetic

table):

• Lits halte santé : 5.1

• Appartements de coordination thérapeutique : 5.1

• Foyer de vie : 5.2

• Maison d’Accueil Spécialisée (MAS) (Specialized Sheltered Houses) : 5.2

• Foyer d’Accueil Médicalisé (FAM) (Medical Sheltered Housing) : 5.2

• Foyer d’hébergement pour travailleurs handicapés: 5.2

• Centre d’hébergement d’urgence et nuitées d’hôtel : 5.1

• Centre d’hébergement et de réinsertion temporaire (CHRS) : 5.1

• Maisons relais : 5.2

• Résidences accueil : 5.2

• Hébergement de stabilisation : 5.1

• Accueil familial social : 5.2

• Appartements associatifs : 5.2

• Familles gouvernantes : 5.2

• Résidences sociales : 5.1

qqqqq We find a list of residential mixed health service in a document of the ‘Mission Nationale d’Appui en

Santé Mentale (februari 2007) 202


KCE Reports 144 Evidence Based Mental Health Services 111

8.4.4.3 The ‘Support mixed teams’

Apart from the full mental health services and the residential mixed services we find

ambulatory support teams organized to help persons who have re-integration problems.

Again, the mental health patients are not the only or principal target population of the

“support mixed teams”; but they can use these services if they need medical-social

support.

As already pointed out before, many psychiatric sectors signed “Conventions” or

written agreements with “mixed services” to enhance collaboration, but not much

information has been found on its practical consequences. (Coldefy 2007 p44)

The figures below refer to the ESMS tree in the synthetic table:

• Equipes psy-précarité : 9.1

• Services d’accompagnement de la vie sociale (SAVS) : 9.1

• Service d’accompagnement médico-social pour adultes handicapés

(SAMSAH) : 9.1

• Groupes d’entraide mutuelle : 10

8.4.5 The ‘Mental health care tree’ in France

In this paragraph, more detailed information is presented on the different services listed

in paragraphs 8.4.4.1, 8.4.4.2, and 8.4.4.3. A table with an overview of available services

in France is presented in chapter 14.1.6.

The data in this report on “full mental health services” rely on Coldefy 2007 187-189, 192 .

Unless otherwise mentioned, the included figures only deal with the “sectorized” full

mental health care, and not with the “not sectorized” mental health care for which no

readily available figures were found. As shown in Figure 8.4 (Chaleix 2006), the “not

sectorized” mental health care represents 24% of the 56.719 full time hospitalization

beds and 10% of the 17.666 partial hospitalization places in France in 2004.

To calculate services per 100.000 population, a rounded figure of 62 million inhabitants

in France rrrrr in 2003 has been used. In 2003, there were 817 sectors in France (Coldefy

2007)

8.4.5.1 Secure services (1)

Secure services as such will not be addressed in this report, as they are out of the

scope.

8.4.5.2 Residential mental health services

The 1985 reforms led to the creation of departments of psychiatry in general hospitals

but most psychiatrics units remained physically separate from general hospitals 191 . In

2000, two thirds of all available beds were located in mental hospitals, one third in

general hospitals (Verdoux 2007) 190 .

• Generic acute

o Hospital (2): In 2003, two thirds of the sectors are specifically involved in

psychiatric hospital emergencies. The emergency intervention teams of

the sectors are composed by 1.1 medical FTE, 1.3 FTE nurse and 0.9 FTE

of other professionals (Coldefy, 2007, p. 41). Emergency services are

growing in the inter-sector service supply, however no numbers are yet

available. In France, residential hospital beds are not subdivided in “acute

beds” and “non-acute beds”, all beds are taken together (see further:

“non-acute hospital”). In some other countries, all psychiatric beds in

general hospitals are counted as “acute” beds, this is also not the case in

France.

rrrrr http://www.insee.fr/fr/themes/tableau.asp?reg_id=0&ref_id=NATnon02151


112 Evidence Based Mental Health Services KCE reports 144

o Non-hospital (3): in the category of “full mental health services”, Centres

de crise and Centres d’Accueil Permanent (CAP) were found. According

to Coldefy 2007, the importance of these services is diminuishing; only 3%

of the sectors provided such services in 2003 (see Table 8.5). From the

category of the “residential mixed services” we can consider the “Centres

d’Hébergement d’Urgence” belonging to this category; they will be dealt

with in the paragraph below.

• Non-acute

o Hospital (4)

Following the ESMS tree, we should make the difference between ‘time limited’ (4.1)

and ‘indefinite stay’ (4.2) but this differentiation is not relevant for France. We

discriminate “full time hospitalization” (including liaison psychiatry) and “night

hospitalization”.

The full time hospitalization in hospitals is reserved to patients who need a close

watch days and nights, mostly in acute situations or for the most serious cases. As a

consequence of the deinstitutionalization policy, the number of public adult psychiatric

beds decreased by 49% between 1987 and 2000 (Verdoux 2007) 190 . In 2004, the total

number of full-time beds amounts to 56.719 beds or 91.4/100.000 population. Of these,

43.072 beds (or 76%) belong to the sectorized psychiatry, which represents only 40% of

the services (hospitals). Further, 13.647 beds (or 24%) belong to the non-sectorized

psychiatry (60% of services) (see Table 8.4, Chaleix 2006). Full time hospitalization is

characterized by a continuously decreasing of the length of stay since 1989 (86 days in

1989 and 41 in 2003 187-189 ). This reduction is associated with the reduction of the

number of beds (public “sectorized” beds: 76.000 in 1989 and 37.000 in 2003 187-189 ),

which was one of the goals of the sectorization. In 2003, a total of 301.925 mentally

disordered persons had been hospitalized (sectorised services only), or 487/100.000

population (Coldefy 2007). When these figures are compared to the residential nonacute

non-hospital full mental health services (see further), it is clear that an

overwhelming part (96%) of the residential full mental health care is provided in

hospitals and not in community-based services.

A special form of hospital care is the ‘liaison psychiatry’. It is a response to the

occurrence of psychiatric problems in patients hospitalized for somatic reasons. In this

case, specific assessment, treatment and orientation are necessary. This function is also

addressed to the caregivers and to the peoples living around the patient. We find such a

function in 75% of the sectors. The average liaison team is composed by 0.7 medical

FTE, 1.9 FTE nurses and 0.2 FTE psychologists (Coldefy, 2007, p. 41). In 2003, these

teams have realized 459.677 acts for 218.318 patients (352 patients/100.000 population)

and another 72.000 liaison acts in inter-sector teams sssss .

In night hospitals the patients are managed at the end of the day or of the week. The

latter patients are persons living in physical autonomy in day-time but particular

vulnerable when by night. The goal is thus the prevention of crises (e.g. anxiety) during

the night when the patient is alone. The number of patients looked after in night

hospitals has been decreasing since 1997. In 2003, 55% of the sectors used the night

hospital with on average 3 places per sector 187-189 ). This means about 2450 places for

France, or 3.9/100.000 population.

o Non-hospital (5)

We will distinguish the residential “full mental health services” exclusively reserved for

the persons with mental disorders from the “residential mixed services” where also

persons with other types of social or health problems can find help.

sssss For the other countries studied in this report, no information on availability of liaison psychiatry has been

found.


KCE Reports 144 Evidence Based Mental Health Services 113

Full mental health services (non-acute non-hospital)

In the category of ‘full mental health services’, we find three different types of

accommodation taking care of a mentally disordered person in the non-hospital

(sectorized) services for non acute care and for a limited time (5.1): the ‘centres de

post-cure ou de réadaptation’ (centre of post-cure or rehabilitation), the ‘appartements

thérapeutiques’ (therapeutic apartments) and the ‘appartements associatifs’ (Associative

Apartments). The ‘centres de post-cure ou réhabilitation’ can be installed in a

hospital but have to be clearly separated from the hospitalization wards. The principal

goal of these centres is the rehabilitation and reinforcement of autonomy of the patients.

In 2003, a total of 1323 patients in France used this type of service (2,1/100.000

population) (Coldefy 2007 p28). The ‘appartements thérapeutiques’ are located in

the city to facilitate the social reintegration. Few patients are supervised by an important

team of care givers. In 2003, a total of 1172 patients in France used this type of service

(1.9/100.000 population) (Coldefy 2007). The patients living in ‘appartements

associatifs’ are considered as normal renters and the medical interventions are

considered as ambulatory interventions. These apartments are fully independent of the

‘referent’ hospital which assures only a medical follow-up. No figures are available; but

Coldefy describes a category “full time other” (indefinite time or not), including in 2003

a total 5874 patients in France (9.3/100.000 population).

We can also consider two types of services for an indefinite time (5.2), the ‘accueil

familial thérapeutique’ (therapeutic familial accommodation) and the ‘service

d’hospitalisation à domicile’ (home hospitalisation). The ‘accueil familial

thérapeutique’ is a form of accommodation reserved to patients who can not go back

to their family. They need a social and affective assistance combined with the therapeutic

follow-up. In 2003, a total of 2590 patients in France used this type of service

(4.1/100.000 population) (Coldefy 2007). Other patients can try to live again in a family

context but may need help and assistance to rediscover the gestures of the daily life,

they chose the ‘service d’hospitalisation à domicile’. Only 42 sectors were using

this form of hospitalization in 2003, for 1090 patients (1.7/100.000 population) (Coldéfy,

2007, p.37 187-189 .

For time-limited services and indefinite time services together, there were 19

users/100.000 population in 2003 (in sectorized psychiatric services).

Residential mixed services (non-acute non-hospital)

In the category of ‘residential mixed’ services, we find 6 different possibilities for a fixed

period of time residence (5.1) and 9 possibilities for an indefinite stay (5.2). This

paragraph is mainly based on Ponssard 202 in 2007. Only a part of the persons received in

these accommodations suffers from mental health problems. No precise figures are

available on the number of users suffering from a mental disorder. Entrance to most of

these accommodations has to be approved by the “Commission départementale des

droits et de l’autonomie des personnes handicapées”.

Time-limited accommodation: the ‘lits halte de soins santé’ are a recent initiative to

shelter persons without any fixed residence and knowing health and social problems. ttttt

Each institution can entail a maximum number of 30 beds for medical and paramedical

cares and a therapeutic follow-up. The stay is limited to two months. This service is

characterized by the obligation to sign a convention with an institution of the same

geographic area having a psychiatric activity. The multidisciplinary team must be

composed by minimum one physician and one nurse. The ‘appartements de

coordination thérapeutique’ are conceived for persons experiencing a situation of

social and psychological frailty.

ttttt Created by the law N°2005-1579, 19 décembre 2005, article 50. Decree 2006-556 of 17 mai 2006

concerning the organization conditions and the functioning of the ‘lits halte soins santé’ (Journal Officiel of

18 mai 2006) (http://www.localtis.fr). Also the ‘Circulaire’ (decree specifying how a law should be

enforced) DGAS/SD.1A N° 2006/47 – 7 février 2006 (http://www.sante.gouv.fr/adm/dagpb/bo/2006/06-

03/a0030038.htm)


114 Evidence Based Mental Health Services KCE reports 144

The personnel have to offer the medical and psycho-social coordination. They are

attached to an hospital or a CMP. uuuuu In the same category of accommodations, we find

also the ‘centres d’hébergement d’urgence’ (CHU) and the ‘nuitées d’hôtels’.

The two services concern individuals without any place to live. They may stay in these

places from one night until several months. For persons experiencing major difficulties

(economic, familial, residential, social insertion and health), the State authorises also

public and private establishments called ‘centres d’hébergement et de reinsertion

sociale’ (CHRS). Following the same philosophy of autonomy and social re-integration

of the individuals, the State creates in 1994 the ‘résidences sociales’. vvvvv They offer

one of two beds instead of a dormitory as in the CHU. When al the presented

accommodations are not adequate, the ‘hébergement de stabilisation’ can be

considered as a complementary residence for a short period of time.

Besides, the residential mixed services organised for a limited period, we find services

offering the same services for a longer or unlimited period. We present briefly the 9

types of this kind of accommodation. The ‘foyers de vie ou foyers occupationnels’

shelter individuals who are unable to work. Nevertheless, they are able to participate to

leisure activities. wwwww The persons accepted in ‘maisons d’accueil spécialisées’

(MAS) are not able to assure their activities of daily living. They need a regular medical

supervision but receive also other services. The patients of the ‘foyers d’accueil

médicalisés’ (FAM) are very deeply handicapped and need constant care and medical

supervision. In 2001, more than 55 % of the residents of MAS and FAM suffered of

intellectual and mental problems (Vanovermeir 2004, p.185 and 226 203 . The Psychiatric

and Mental health Plan 2005 – 2008 (Plan Psychiatrie et Santé Mentale – PSM) 204 plans

to create 7 500 new places in MAS and FAM during the period 2005 – 2008. We find

also the ‘foyers d’hébergement pour travailleurs handicapés’ which are reserved

for adults exercising an activity during the day xxxxx . These accommodations do not offer

medical care but only a social support and medical acts are performed by independent

physicians. The ‘maisons relais’, is an experimental accommodation sheltering people

who cannot find housing for social, psychological or psychiatric reasons. They are

organized as a cluster of 10 to 25 apartments with a collective room. The residents can

receive medico-psychological and social support assured by the host. The ‘résidences

accueil’ yyyyy is also an experimental type of accommodation based on the same principles

as the ‘maisons relais’ but specifically developed to shelter people who have

psychological problems linked with chronic mental pathology. zzzzz The responsible of this

accommodation has to contract a convention with a team of the psychiatric sector. For

persons who have no more capacity to stay alone at home, there exists the system a

familial social sheltering (accueil familial social). aaaaaa The host receives remuneration

from the State. The ‘appartements associatifs’ are reserved to autonomous persons.

These accommodations are managed by an association which receives the warranty of

the communes. The PMS plans 204 to create 500 new ‘appartements associatifs’ during the

period 2005 – 2008. Persons who cannot live alone can be sheltered by a ‘famille

gouvernante’ if their situation does not require a hospitalization. This concept was

developed by the UDAF (Union départementale des associations familiales) of the

Marne. This is a specific category of apartments associatifs with the intervention of a

‘gouvernante’ living in the same building as the residents 204 . The gouvernante provides

support to the persons for the acts of the daily live and is responsible for cooking,

hygiene, medication, medical and administrative formalities etc. He/she is in charge of 5

or 6 persons living in two apartments.

uuuuu Decree N°2002-1227, 2002 3td October. Circulaire DGS/DGAS/DSS/2002/551, 2002 30 th October

vvvvv Decree N°94.1128, 94.1129 and 94.1130 – 1994 23 th December and Circulaire 2006 4 th july – Direction

générale de l’urbanisme, de l’habitat et de la construction et direction générale de l’action sociale

wwwww Code de l’action sociale et des familles L312-1, L344-5, R344-29 et suivants, D344-35 et suivants

(http://vosdroits.service-public.fr/particuliers/F2005.xhtml?p=1)

xxxxx Code de l’action sociale et des familles L344-5 (http://vosdroits.service-public.fr)

yyyyy Although this type of accommodation belongs to the « full mental health services », it is mentioned here

because it is financed by the regional departments and not by the social security.

zzzzz Note d’information DGAS/PIA/PHAN N° 2006-523 – 16 novembre 2006

(http://www.sante.gouv.fr/adm/dagpb/bo/2007/07-01/a0010053.htm)

aaaaaa Note d’information DGAS/2C/2005/283 – 15 juin 2005 (http://www.famidac.fr/article259.html)


KCE Reports 144 Evidence Based Mental Health Services 115

Table 8.6: Evolution of the number of MAS and places

Years Number of MAS Number of places Evolution (%)

1998 (*) 297 11 775

2001 (**) 360 14 500 23,1%

2005 (***) 415 16 703 15,2%

Sources: (*)http://archives.handicap.gouv.fr,(**) Vanovermeir 2004, p. 173 203, (***)Burckbuchler

2004 205

Table 8.7: Evolution of the number of FAM and places

Years Number of FAM Number of places Evolution (%)

1998 (*) 191 6 235

2001 (**) 278 9 200 47,6%

2005 (***) 347 10 309 12,1%

Sources: (*)http://archives.handicap.gouv.fr,(**) Vanovermeir 2004, p.207 203, (***) 205

8.4.5.3 Day and structured activity

Information on non-sectorized “full mental health services” was only found for “day

hospitals”. No information on other than “full mental health services” was found;

however, 20% of the psychiatric sectors have an agreement (“Convention”) with a local

service for employment, professional education, or social re-integration (Coldefy 2007

p44) 187-189 .

• Acute (6) No specific and accurate information was found on this point.

• Non-acute (7)

The number of users of this type of services doubled between 1989 and 2003 (Coldefy

2007, p30). The structure of the ESMS tree makes the difference between ‘High’ and

‘Low’ intensity. This distinction corresponds to the two types of non-acute day mental

services: on the one hand, the day hospital and on the other hand, the ‘atelier

thérapeutique’ (therapeutic workplace) and the Centre d’Accueil Thérapeutique à Temps

Partiel (CATTP). Despite a formal principle distinction, the experts consider that the

distinction on the field is not always so clear because the CATTP is a very flexible

organization 187-189 . The evolution of the number of CATTP and day hospitals

characterizes the development of structures closer to the patient’s living place because

62% of the day hospital places and 88 % of the CATTP are situated outside the

‘attached institution’ in 2003 187-189 .

o High intensity (7.1)

In the day hospital, the patients receive polyvalent and intensive care during all or a

part of the day and during one or more days of the week. Individualized therapeutic

protocols are revised periodically to avoid the ‘chronicization’ of the patient. The goal

is the re-integration of the patient into the society. Sectorized day hospitals 187-189

accounted for 46.883 patients in 2003, or 75,6/100.000 population/year. Non-sectorized

part-time hospitalization accounts for 10% of all part-time hospitalization places (Chaleix

2006). Given the fact that night hospitalization is not common (see above), it can be

estimated that another 8,4 patients/100.000 population/year use non-sectorized day

hospitalization; so that day hospitals (sectorized and non-sectorized) were used by 84

patients/100.000 population/year.

o Low intensity (7.2)

The activities in a ‘centre d’accueil thérapeutique à temps partiel’ (CATTP) are

less intensive. The goals of the interventions consist in maintaining or promoting the

patient’s autonomy by support and group therapy. The CATTP is the normal follow-up

for patients coming from day hospital because the interventions are more oriented to

the social reintegration of the patients. Since 1995, the CATTP is the more used part

time intervention system with 68.837 patients (sectorized psychiatry only) or

111/100.000 population 187-189 in 2003.


116 Evidence Based Mental Health Services KCE reports 144

The principal goal of the ‘atelier thérapeutique’ is the professional and social

rehabilitation using artistic, traditional and sports activities to develop the relational

capacities of the patients. In 2003, this service was used by 4882 patients (7.9/100.000

population, sectorized psychiatry only) 187-189 .

Other, less well defined services exist, in 2003 they served 14.897 patients (24/100.000

population)

8.4.5.4 Out-patient and community mental health services

This paragraph contains information on “full mental health services”: Centres médicopsychologiques

or CMP, Centres d’Accueil Permanents or CAP, and Centres de crise. (CAP and

crisis centres can also provide residential care, see “residential generic acute nonhospital”

services). ‘Equipes psy-précarité’ can also considered to be full mental health

services. For the “full mental health services”, no information on non-sectorized

ambulatory services was found; ambulatory services by private psychiatrists or

psychologists are mentioned briefly.

“Mixed” support teams that serve persons with all types of disabilities (not only mental

disorders) are also discussed, they belong to the category “continuing care, mobile”:

‘service d’accompagnement à la vie sociale’ (SAVH), and ‘service d’accompagnement medicosocial

pour adultes handicapés’ (SAMSAH).

Although hospitalization remains a very common practice in France, the ambulatory

mental health care services become more and more important in mental health care.

Between 1989 and 2003, the number of consultations in the CMP has doubled.

According to Coldefy et al 187-189 , outpatient psychiatric care comprised 86% of all

psychiatric care in 2003, as compared to 79% in 1989.

• Emergency care (8)

o Mobile (8.1)

A few CMP provide mobile services in Centres d’Accueil Permanents (in non-residential

form). Emergency outreaching is not common practice in France (as underlined in

personal communications with French experts).

o Non-mobile (8.2)

In this category, we find the CMP (Centres medico-psychologiques) who can take

care in case of emergency; 83% of the sectors provide emergency CMP care (Coldefy

2007 p39). CMP can also rely on emergency care centres (in this case, we speak about

CAP or Centres d’Accueil Permanents). They organise emergency measures and, if

necessary, the first needed care. The crisis centres (Centres de crise) can also

intervene in case of emergency situations and acute distress. According to Coldefy

2007, the importance of CAP and crisis centres is diminuishing; only 3% of the sectors

provided such services in 2003 (see Table 8.5). CAP and crisis centres can also provide

residential care (see “residential generic acute non-hospital” services).

• Continuing care (9)

o Mobile (9.1)

The CMP, the cornerstone of the psychiatric sector, can offer ambulatory care at the

living place of the patients. In 2003, 184.520 patients used this type of service, or

297patients/100.000 population /year. This is about 19% of all patients served by the

CMP in 2003.

The ‘équipes psy-précarité’ are mobile teams planned by the Psychiatric and Mental

health plan 197 . They are specialized in psychiatric care and are composed by physicians,

nurses and psychologists. bbbbbb These teams follow people experiencing major difficulties

in access to mental health care, and try to motivate the patients to participate in regular

care. They have also to promote the interface between the psychiatric sectors and the

socials teams.

bbbbbb Circulaire DHOS/02/DGS/6C/DGAS/1A/1B/521 du 23 novembre 2005 (cited in 202)


KCE Reports 144 Evidence Based Mental Health Services 117

In the group of the “mixed support teams”, two types of mobile teams offer social and

medico-social support cccccc to persons with different types of disabilities, but their role

for persons with a mental disorder has been emphasized in the Mental Health Plan

2005-2008 (Ponssard 2007) 202 . The first one, the ‘service d’accompagnement à la

vie sociale’ (SAVH), gives a support to patients to restore familial, social, professional,

scholar or academic relations. These teams are composed of social assistants,

psychologists, advisers in social and familial economy, educators. The second one, ‘the

service d’accompagnement medico-social pour adultes handicapés’

(SAMSAH), is charged of a complementary mission. Indeed, it has been clearly

underlined by several reports, especially MP Alain Milon’s report in April 2009, that

these teams play a major role in the quality of long-term observance of medication. The

team includes always a physician and has to offer a medical and paramedical support. All

the interventions of these two teams are implemented at home of the patient or on

every place where he/she exercises his/her activities.

o Non-mobile (9.2)

The CMP or Centres medico-psychologiques are the cornerstone of the

psychiatric sector. As already mentioned (see 8.4.2.1), there were 2070 CMPs in 2003

in the 817 sectors.

In 2003, 804.909 patients were seen in consultation at the CMP, or 1298

patients/100.000 population/year. This is about 81% of all patients served by the CMP in

2003; the rest (19%) of the consultations take place at the living place of the patient (see

above) (Coldefy 2007).

Psychiatrists, psycho-analists and psychologists also provide ambulatory

continuing, non-mobile care, that can be reimbursed or non reimbursed. The

consultations of psychiatrists are covered in the general scheme. The majority of the

contacts between the psychiatrist and his patient are consultations at the psychiatrist

practice dddddd . We find also out-patient consultations in the hospital and, more rarely, in

private clinics 186, 206 . We find three types of psychiatrists in function of the applied price

system.

• The psychiatrists of the sector 1 (6 psychiatrists on 10): apply fixed tariffs.

The compulsory health insurance reimburses 70 % of the price and the

patient has to pay the co-payment. This co-payment can be covered by the

complementary insurance of the patient. The price of the consultation if fully

reimbursed for patients beneficiaries of the ALD (affection of long duration)

system.

• The psychiatrists of the sector 2: determine freely their tariffs with ‘tact and

moderation’. The reimbursement (70 %) is based on the tariff of sector 1.

Complementary insurances can cover completely or partially the charge

exceeding the statutory fee for a fixed number of all the consultations.

• The psychiatrists working out of the convention. They are fully free to fix

their tariffs and the compulsory health care insurance reimbursed only a lump

sum of 1,46 €.

The optimal reimbursement of the health care system is only applied when the patients

respect the coordinated and individualized care path ‘parcours de soins coordonné et

individualisé’. Following this system, each patient older than 16 years has to choose a

‘reference physician’ (médecin traitant) who play the role of a gate-keeper. Only the

patients younger than 26 years are free to consult a psychiatrist outside the care path.

cccccc Loi 2002-2 du 02 janvier 2002 et décret N° 2005-223 du 11 mars 2005 (Cited by Ponssard 2006)

dddddd 80 % following an inquiry of INSEE realized between October 2002 and September 2003. Almost 1 200

000 persons have declared a contact with a psychiatrist, a psychologist or a psychoanalyst during this

inquiry, this represents 2 % of the population (see Chapireau 2006 206)


118 Evidence Based Mental Health Services KCE reports 144

On the other hand, the consultations of psychoanalysts eeeeee and psychologists ffffff in the

ambulant sector (at the practitioner’s office) are not reimbursed and are fully charged

to the patients. Some complementary insurances cover partially a certain number of

sessions.

8.4.5.5 Self-help and non-professional mental health services

So far care by volunteers or family has never been acknowledged, neither legally nor

financially. Family support however plays an important role, especially in a context of

non institutionalized patient management and increased home care. As to self-help, the

Plan Santé Mentale 2005-2008 (PSM) 197 provides subsidies to support the creation of

‘groupes d’entraide mutuelle’ (GEM) gggggg to fight against isolation and to support

persons suffering of psychic problems hhhhhh .

In the organization of health care in general, users and family associations have gained

over the last decade a growing position (Verdoux, 2007) 190 . Their role has been

specified in the recent laws, and members of patients’ associations are now part of

hospital management boards, national consensus conferences etc. Nevertheless, the

mental health care users associations are represented in only 16% of the sectors (2003).

The representation of their families is hardly higher with 23 % of the sectors. This

situation could change because the Mental Health Plan 2005-2008 considers the

intervention of the care user and his family as a priority for the future.

Key points

• Desinstitutionalization has been the main trend of the French policy for the

last decades.

• Sectorization is the key organizational principle of mental health care

supply. However it did not lead to massive closure of psychiatric hospitals

(like in some other western countries)

• Hospital beds decreased significantly, day care doubled in 15 years and

outpatient care grew constantly.

• However, for patients in need of residential care, there are very few options

outside the traditional hospitalization.

• Mapping of the territory and distribution of health care supply remains

uneven across regions. Actual access to the whole range of services is

problematic in some geographical areas.

eeeeee Psychoanalysis : « Method of clinical psychology, investigation of the deep psychical process ; therapeutic

method coming from this investigation, these methods were elaborated by Sigmund Freud and its

disciples (definition of Alain Rey cited by Chapireau 206)

ffffff Psychologist : the required qualifications to act as psychologist are fixed by the Law 85-772 of 27 July

1985 206.

gggggg Loi N°2005-102 du 11 février 2005. Circulaire DGAS/PHAN/3B/2005/418 du 29 août 2005 (cited in

Ponssard 202)

hhhhhh We find an appraisal of the organization and the financing of these GEM in the circulaire

N°DGAS/3B/2007 du 30 mars 2007. In 2006, the State has delegated 18 M€ to the DRASS (Directions

Régionales des Affaires Sanitaires et Sociales) to finance 259 GEM among which 142 ware created in

2006. 20 M€ were planned for 2007. 14 department on 100 have not created GEM in 2006 and 17

departments had only one GEM.


KCE Reports 144 Evidence Based Mental Health Services 119

8.5 FINANCING OF THE MENTAL HEALTH CARE SECTOR

8.5.1 Global data

The total French health expenditure was 10.5% of GDP in 2003 (Verdoux 2007) 190 .

According to Verdoux (2007), the mental health budget represented 9.4% of the general

health budget in 1998. According to Coldefy (2007) 187-189 , the mental health budget (not

including prevention) represented 10.6% of the general health budget in 2005. The

WHO Mental health atlas 2005 iiiiii mentions that 8% of the total health budget is spent

on mental health. The cost of full time psychiatric hospitalizations represents 80% of

mental health expenditure (Verdoux 2007).

In France, as in many other countries, the whole range of care provided to persons with

mental disorders are matters for two different budgets, both from a legal and financial

point of view, and the rationale behind is the following:

• Clinical care, strictly speaking, that is provided by health professionals

only (GPs, Psychiatrists, Nurses) are matters for “Health Care” and thus

funded by the Social Security system.

• Social and psycho-social care (self-support, activities of daily living,...) that

are provided by other professionals are funded by the local branches of

national public institutions and/or by local public authorities, but that are not

a matter for Health Care as such.

• Combined funding can be implemented on very specific subjects.

8.5.2 Data per sector of activities

In the table below, financing is described following the ESMS tree if the data are

available. Main references are Coldefy 2007 187-189 and Ponssard 2007 202 .

Table 8.8: Description of the financing of the different mental health (pure

and mixed) institutions and teams

Services or institutions

Full Mental Health Services

Financing

Complete hospitalisation Social security - ONDAM

Night Hospital Social security - ONDAM

Accueil familial thérapeutique Social security - ONDAM

Centre de postcure Social security - ONDAM

Appartement thérapeutique Social security - ONDAM

Centre d’Accueil Thérapeutique à Temps Partiel Social security - ONDAM

(CATTP)

Service d’hospitalisation à Domicile (HAD) Social security - ONDAM

Day Hospital Social security - ONDAM

Atelier thérapeutique Social security - ONDAM

Centre d’Accueil Permanent (CAP) Social security - ONDAM

Centre de crise Social security - ONDAM

Centre Médical Psychologique (CMP) Social security - ONDAM

Unité d’hospitalisation somatique Social security - ONDAM

Institution substitutive au domicile Social security - ONDAM

Apartement associatif Social security - ONDAM

Psychiatrist Social security - ONDAM

Psychologist Social security - ONDAM

Psychoanalyst Social security - ONDAM

Residential Mixed Services

Lits haltes soins santé (LHSS) ONDAM medical-social. Global budget based on a

lump sum per day and per bed. 90 euros for 2006

and revised each year.

Appartements de coordination thérapeutique ONDAM medical-social. The food costs are on

iiiiii http://www.who.int/mental_health/evidence/atlas/profiles_countries_e_i.pdf


120 Evidence Based Mental Health Services KCE reports 144

(ACT) charge of the residents. Financial interventions of

the collectivities and co-payment of the residents

Centres d’hébergement d’urgence (CHU) et

nuitées d’hôtel

are deducted of the global budget

Ministère de l’emploi, de la cohésion sociale et du

logement (Direction générale de l’Activité Sociale –

DGAS)

Nuitées d’hôtel Direction Départementale des Affaires sanitaires et

Sociales (DDASS)

Centres d’hébergement et de réinsertion sociale Ministère de l’emploi, de la cohésion sociale et du

(CHRS)

logement - Direction Départementale des Affaires

sanitaires et Sociales (DDASS) – financial

participation of the residents in function of their

revenues (between 9 and 40 % depending of the

familial situation) jjjjjj

Résidences sociales Several financing : aide à la gestion locative,

« Département » - (General Council), fond de

solidarité pour le logement

Hébergement de stabilisation Direction Départementale des Affaires sanitaires et

Sociales (DDASS)

Foyer de vie ou foyer occupationnel « Département » - (General Council) and personal

intervention of the resident. This financial

intervention is based on the revenue of the resident.

Maison d’Accueil Spécialisée (MAS) Fully financed by the social security by means of a

daily lump sum. After a period of 45 days, the

patient has to pay a per diem intervention

Foyer d’Accueil Spécialisé (FAS) Residence financed by the departmental social aid /

aide sociale départementale (General Council).

Foyer d’hébergement pour travailleurs

handicapés

Cares are financed by social security – ONDAM.

The financial charge for the resident is calculated on

basis of their resources giving an upper limit to leave

him a minimum financial autonomy. The department

can cover a part of the costs. Medical costs are

covered by the social security and paid by a fee for

service.

Résidences accueil DRASS (Direction Régionale des Affaires Sanitaires

et Sociales) and Direction de l’équipement. The

host receives a lump sum per place and per day

from the State.

Maisons – relais Functioning financed by the State. Resident pays a

monthly sum equal to 15 % of their resources.

Accueil familial social « Département » (General Council)

Appartements associatifs The patient (resident) pays a rent and can receive a

financial help in function of their resources.

Familles gouvernantes The ‘gouvernante’ is paid by the residents who can

receive a special allocation from the department

(allocation compensatrice pour tierce personne)

Support Mixed Teams

Equipes psy-précarité Reimbursement of the medical acts – social security

Service d’accompagnement à la vie sociale (SAVS) « Département » (General Council)

Service d’accompagnement médico-social pour Social security and « Département » (General

adultes handicapés (SAMSAH)

Council)

Groupes d’entraide mutuelle (GEM) Subsidization from the State (average amount per

GEM: 75 000 euros

jjjjjj See http://www.adai13.asso.fr/fiches/log/log_chrs.htm


KCE Reports 144 Evidence Based Mental Health Services 121

8.5.3 Key issues on financing of psychiatric care

The general principle that divides funding between mental health or clinical care, and

(psycho-) social care or welfare, has several draw-backs.

8.5.3.1 Lack of funding continuity between clinical and psycho-social care

One of the weaknesses of the separation of health and social care budgets is that it does

not guarantee funding continuity between purely clinical care, psycho-social care, and

social support, as these different types of care are matters for different budgets and are

within the remit of different institutions. This problem was clearly identified by the

Clery-Melin Report in 2003 (Authors: Dr Clery-Melin, Pr Kovess, and Dr Pascal; see

paragraph 8.4.3.1). The Mental Health Plan 2005-2008 augmented the budget for

psycho-social care supply (see paragraph 8.4.3.2). However, the current situation is still

far from being satisfactory.

8.5.3.2 Local authorities responsible for funding of psycho-social care

As underlined by the Milon report and also by the Haute Autorité de Santé, social and

psycho-social care is largely funded by local public authorities, especially the

“Département” (French equivalent of the Belgian “Province”) whose governing body is

the “Conseil Général / General Council”. However, this can be hampered by the

following factors:

• Local authorities in France are entrusted with administrative or day-to-day

budget management but they have no regulatory power. Therefore,

today’s institutional framework does not leave them much room for

manoeuvre.

• The financial support they can bring basically depends on the own financial

capacity of each “Département”, and its wealth. This takes us back to

the notion of unequal access to health care in the different French

“Departement”.

• In today’s legal framework, the latter are not under a legal obligation to

guarantee a specific level of funding (amount of money, number of beds,

level of workforce, etc…) to mental health care.

• This puts things back in the wider context of local political arbitration, as

actual funding and funding largely depend on a political commitment.

Therefore, there is no guarantee that the patients’ needs can actually be met.

8.5.3.3 Transparency problems

Important problems remain unsolved in the field of psychiatric care, which has an

impact on the optimal use of health care funds. One of them is the lack of

transparency of psychiatric departments: the main hindering factor for an effective use

of healthcare funding is the lack of data and detailed information concerning the

psychiatrists’ activity in public hospitals. This problem takes us back to a problem of

transparency culture, as underlined in personal contacts with French experts.

Key points

• Continuity of funding between purely clinical care and psycho-social care is

not guaranteed.

• Funding of psycho-social care largely depends on the financial capacity of

local authorities, and is very uneven across regions.

• Financial issues are difficult to address, because of a lack of transparency of

psychiatric departments.


122 Evidence Based Mental Health Services KCE reports 144

8.6 THE FRENCH MENTAL HEALTH CARE ORGANIZATION:

DISCUSSION

During the last decades, the cornerstones of the reforms of the French mental health

care system were “de-institutionalization” and “sectorization”.

Since then, the “de-institutionalization” led to a marked decrease in hospital beds:

between 1987 and 2000, the number of public adult psychiatric beds decreased by 49%

(Verdoux 2007) 190 . Nevertheless, hospital-based care has still an overwhelming

importance, and is associated with a marked underdevelopment of residential

community services and lack of adapted housing for the most disabled patients

(Verdoux H 2007) 190 (Coldefy, 2007, p. 36) 187-189 .

The goals of the “sectorization” policy were to promote the development of

community care, to assure the access to mental health care for every-one 190 and to

make psychiatry evolve outside the hospital 191 . At the centre of the sector, the

multidisciplinary teams of the CMPs (Centre medico-psychologique) should provide

patient care, continuity of care, and coordination of medical care and psycho-social

support. The last decades, outpatient ambulatory services by the CMP grew constantly

and day care doubled in 15 years (Coldefy 2007).

However, several recent reports emphasize that many of the initial goals have not been

reached so far: the Cléry-Melin report (2003), the assessment of the Mental Health Plan

2005-2008 by the Department of Health in 2006, the publication by Coldefy (2007 and

2009), the Rapport Couty (2009), the Rapport Milon (2009), the IRDES report (2009)

(see paragraph 8.4.3). They all mention the same fundamental problems of domination

of hospital care, uneven distribution of service supply, long waiting lists and lack of

coordination and continuity of care.


KCE Reports 144 Evidence Based Mental Health Services 123

9 THE NETHERLANDS

9.1 LITERATURE SEARCH: METHODOLOGY

See general methodology. No information (references, data…) has been included after

August 31, 2009.

9.2 GENERAL HEALTH CARE ORGANISATION

9.2.1 History

In the 1970’s centralized government coordination and planning was the leading

principle and model in Dutch health care. The government had ultimate control over

the planning of care facilities, the pricing of provisions, and the macroeconomics of

health care expenditures. Since the late 1980’s several policy reformations took

place kkkkkk , whereby the central government (the Ministry of Health, Welfare and Sport

(Ministerie van Volksgezondheid, Welzijn en Sport, VWS)) decentralized certain

competencies to provincial and local governments. Since then, the regional government

had the responsibility to develop a planning for care facilities based on an analysis of

local needs and availability of services. Draft proposals were then submitted to the

health minister for approval, after receiving advice from the Hospital Provision Board.

The Dutch health insurance model separated three health insurance compartments.

1. The first, national compartment covered the exceptional medical expenses

associated with long-term care or high-cost treatment, where the expense is

such that it cannot be borne by individuals or adequately covered by private

insurance. This compartment of care was covered under the Exceptional Medical

Expenses Act (AWBZ).

2. The second compartment covered regular, necessary medical care under the

Sickness Fund Act (ZFW). Included were the sickness fund insurance

(compulsory for those under a certain income) and the private health insurers

(mostly voluntary).

3. The third compartment covered the voluntary supplementary forms of care

regarded as being less necessary. The costs are covered by private medical

insurance. Supplementary insurance can be taken out to cover the costs of these

kinds of care, which are not included in the first or second compartment (e.g.

dental insurance and extensions of the insurance package to cover specific items,

such as glasses or a higher standard of hospital accommodation).

9.2.2 Recent changes

9.2.2.1 Health insurance act (ZVW)

Since a few years, important new changes have been introduced, under the credo “Less

government, more market”. The implementation of the Health Insurance Act

(Zorgverzekeringswet (ZVW); January 1, 2006) is the first step in a reform process that

is planned to last to at least 2012 llllll . The new legislation led to the abolishment of

previous health insurance laws (Sickness Fund Act (ZFW), Hospital Planning Law etc).

The Health Insurance Act makes health coverage by a private health insurer statutory

for everybody. Insurers are at the same time responsible for “buying” health care from

health care providers; they must provide a standard benefits package (included e.g.

general practitioners, drugs) and can’t deny access to citizens, but they are free to offer

additional services or different packages for different prices. Since insurers can “buy”

services from different care providers, they can negotiate on prices and competition

among the care providers is introduced. Also, because citizens can choose freely their

insurer, there are incentives for the insurers to provide best quality at the best price.

kkkkkk http://www.euro.who.int/Document/E84949.pdf

llllll http://www.hpm.org


124 Evidence Based Mental Health Services KCE reports 144

To prevent “cream skimming”, there is a complementary system at the national level

that compensates insurers for the risk of insuring certain categories of patients, e.g.

patients with chronic illnesses. To make it possible for insurers and care providers to

compare prices for services provided mainly in hospitals and by the mental health care

services (GGZ, Geestelijke Gezondheidszorg), the DBC system (introduced mmmmmm in

2005) is used (see further).

9.2.2.2 Exceptional Medical Expenses Act (AWBZ)

Whereas the new system that was started in 2006 applies to the previous “secondary”

and “third” insurance compartment, all citizens remain covered by the national,

statutory “first” compartment, the Exceptional Medical Expenses Act (AWBZ) scheme

for a wide range of chronic care services such as home care and care in nursing homes.

However, the AWBZ recently went through several changes as well.

Since 2003, care reimbursed by the AWBZ typically is not allowed based on a type of

institution or care service, but on “Functional indications”. There exist 5 main Function

indication domains: nursing, treatment, accommodation, personal care (help with ADL

i.e. activities of daily living), guidance (help to organize life, provision of daytime

activities). The decision whether someone is allowed reimbursement for services in one

or more of these AWBZ domains, belongs to the competency of a national,

independent agency (CIZ, Centraal Indicatieorgaan Zorg). If someone has an indication

for a certain domain, he can choose which type of service within this domain is most apt

to his personal situation or which service he prefers. There is a small out-of-pocket

contribution for the service users. A second reformation, effective from 1st Jan 2009,

abolished the uniform AWBZ reimbursement for long-term intramural care, and

adapted it to the intensity of care (zorgzwaarte nnnnnn ): reimbursement is higher for

persons in need of more intensive care.

The third and probably the most important change, is the decision to downsize the

AWBZ. It was felt that the services belonging to its responsibility had become too

broad: originally only long-term intramural care was subsidized, but due to the gradual

reconversion from intramural to extramural care, other types of care became

reimbursed as well, such as home nursing etc. It was decided to return to the original

AWBZ indications: insurance for exceptional medical expenses associated with longterm

care or high-cost treatment, where the expense is such that it cannot be borne by

individuals or adequately covered by private insurance. Services not in line with this

mission would be positioned under the ZVW (Zorgverzekeringswet, Health Insurance

Act 2006), or under the WMO (Wet Maatschappelijke ondersteuning, Social support

Act, 2007).

9.2.2.3 Social support Act (WMO)

The WMO oooooo or “Wet Maatschappelijke ondersteuning”, effective as from 2007, puts

an end to various rules and regulations for handicapped people and the elderly. It

encompasses the Services for the Disabled Act, the Social Welfare Act and, as already

mentioned, parts of the Exceptional Medical Expenses Act (AWBZ). The WMO makes

the municipalities responsible for setting up social support and welfare, such as support

to run the household, help with mobility e.g. wheel chairs or an elevator at home,

support to carers and volunteers, psychosocial support e.g. to homeless people etc. It

was felt that the municipalities are more in the position to estimate the needs of citizens

in these domains than the national Government, and that coordination between the

welfare services under their responsibility would be easier. Also, it would be easier to

control the budgets since fixed budgets would be distributed among the municipalities,

which would be responsible for dividing it according to the urgency of the different local

needs.

mmmmmm http://www.minvws.nl/dossiers/dbc/

nnnnnn http://www.minvws.nl/dossiers/zorgzwaartebekostiging/

oooooo http://www.minvws.nl/en/


KCE Reports 144 Evidence Based Mental Health Services 125

9.3 GENERAL FINANCING OF HEALTH CARE

In the Netherlands, the total 2004 health expenditure amounted to 9.2% of the

GDP pppppp . In 2005 public sources financed 65.7% of the total health expenditure. In

2006 this proportion had risen to around 78% qqqqqq .

The Dutch statutory health insurance system (ZVW, 2006) is financed by a mixture of

income-related contributions and premiums paid by the insured. Contributions are

collected centrally and distributed among insurers based on a risk-adjusted capitation

formula. Additionally, as already explained, each individual has to purchase his own

insurance by paying a contribution (premium) to an insurer of his choice. In 2006 the

average annual premium was €1050. The government pays for the premiums of children

up to the age of 18.

In February 2005, a DRG-like case-mix system based on 'diagnosis treatment

combinations' (DBCs) was introduced for the registration and reimbursement of

hospital and medical specialist care as well as mental health care rrrrrr . The main

objectives of the introduction of the DBC system were to increase transparency of

hospital and specialist care, to realise the transformation from a supply-led to a demandled

system, increase efficiency and facilitate regulated competition between health care

providers.

DBCs are defined as the whole set of activities (diagnostic and therapeutic

interventions) of the hospital and medical specialists from start till discharge. Episodes of

care are identified, and in the DBC case-mix system the type of care (regular,

emergency & chronic), the diagnosis (ICD 10 coding) and the treatment (outpatient or

residential; nature of treatment) have to be identified.

In the DBC case-mix system, a distinction is made between DBCs with fixed prices (list

A) and with negotiable prices (list B). For DBCs on list A, fixed tariffs exist that

hospitals have to charge to health insurers and patients. These tariffs apply to all

hospitals and include two separate components: a reimbursement of hospital costs and

an honorarium for medical specialists. The level of production of a hospital is negotiated

based on these DBC’s with insurers. If the expenses of the hospital exceed the

allowable costs, the loss is for account of the hospital. Prices of list B DBCs result from

negotiations between hospitals and health insurers. Only elective DBCs have been

selected for list B. Health insurers may employ different DBC prices for different

hospitals. Likewise, hospitals may negotiate different prices for the same DBC with

different health insurers.

The initially developed DBC system appears to be too complex (more than 30 000

DBCs etc.). For this reason, mid 2009 the DOT system has been introduced, currently

only for registration, and as from 2011 on also for cost declaration. The DOT system

(“DBC’s Op weg naar Transparantie”, DBCs on their way to Transparency) uses the

ICD-10 classification and contains about 3000 “product classes”. The introduction of

the DBC-based financing of the hospitals is also complex, and it has been decided

that ssssss for the year 2009, DBCs of list B can maximally account for 34% of the full

hospital cost.

pppppp WHO 2008

qqqqqq http://www.commonwealthfund.org/usr_doc/LSE_Country_Profiles.pdf?section=4061

rrrrrr Cost assessment and price setting of inpatient care in the Netherlands. The DBC case-mix system J. B.

Oostenbrink & F. F. H. Rutten Health Care Manage Sci (2006) 9: 287–294

ssssss http://www.minvws.nl/dossiers/dbc/voor-medewerkers-in-de-zorg/dbcs-in-ziekenhuizen/


126 Evidence Based Mental Health Services KCE reports 144

9.4 MENTAL HEALTH CARE ORGANISATION

9.4.1 History

Mental health care in the Netherlands has been through major reforms in the second

half of last century tttttt .

Since the early ‘1980s reformations led to the introduction of alternatives for residential

psychiatric treatment and care. The creation of “Regional centres for ambulatory mental

health care (RIAGG)” was intended to foresee in easily accessible ambulatory

treatment. In the same period the “Regional institutions for sheltered living, regionale

instellingen beschermd wonen, RIBW) were created for people that needed supervision,

but could live outside the hospital infrastructure. Psychiatric care was taken out of the

insurance package covered by the Sickness fund act (ZVW) and fully placed under the

Exceptional medical expenses act (AWBZ), to facilitate the substitution of intramural

care by extramural care such as RIAGG and RIBW.

In the next reformation wave that started at the beginning of the 1990’s, collaborative

practice between mental health care organisations was heavily promoted; even the

merging of several mental health care institutions was stimulated. Each region should

provide all types of care services, in an integrated way, to make sure that continuity of

care could be guaranteed (continuity of care or “ketenzorg”). The regions succeeded in

their mission (“regionalisering”): by 2005, forty large integrated mental health care facilities

were responsible for most of the Dutch mental health cure and care supply; and the

whole country had no more than 3 general psychiatric hospitals left (see Figure 9.1).

This will be further dealt with below.

9.4.2 Specific programmes: care programs and care circuits

During the same period, the development of Mental health Care programs uuuuuu was

stimulated as well; these programs should be as much as possible based on solid

scientific evidence. A (mental health) care program vvvvvv is a meaningful set of cure and

care activities for a certain target group, e.g. depressions in the elderly. Diagnosis,

different treatment options, support, and after-care all belong to the same care

program. For each individual patient, a care plan can be constructed within the

framework of the care program. Basic care programs are provided by the Trimbos

Institute (see further) and exist for e.g. depression, eating disorders, anxiety disorders,

double diagnoses, and also for severe and persistent psychiatric problems. Most (but

not all) of these Basic care programs are organized around a specific diagnostic

category. The Trimbos Institute estimated in 2007 that 60% of the mental health care

services used care programs, and that 850 (regional) care programs were used for 40

different target groups. In a next step, these 850 care programs will be evaluated on

their content and quality.

Gradually a consensus grew that is most practical to distinguish 8 general “mental health

Care circuits”: children and adolescents, adults, elderly persons, forensic psychiatry,

addiction care, long-term care and accommodation, primary mental health care and

mental health prevention.

tttttt http://www.minvws.nl/kamerstukken/cz/2008/aanbieding-van-de-trendrapportage-ggz-2008.asp

uuuuuu http://www.trimbos.nl/publicaties/2007/06/zorgprogrammering-in-de-ggz-zet-door--de-stand-van-zaken-in-

2006

vvvvvv Programma’s in de GGZ, Handreiking voor zorgprogrammering. Verburg, Hv; Rest, Ev; Trimbos institute

2005.


KCE Reports 144 Evidence Based Mental Health Services 127

9.4.3 Most recent changes

At the beginning of the new century, criticisms on the care organization grew, mainly

because mental health care services were integrated with other mental health care

services but not with other cure and care service provisions (“verkokering”). This led

to an isolated position of mental health cure and care, and also of its patients; and it also

gave the large care providers (too) much influence and the patients too little freedom of

choice. Moreover, it was felt that the treatment of mental disorders belongs to the field

of medical care and the ZVW, and it was stressed that this type of care often does not

correspond to the field of AWBZ.

The most recent policy reforms in the Dutch mental health care system date from

2006, and take as a starting point that mental health care should be part of a network of

other (health) care and welfare facilities. This network should not be limited to mental

health care services, but should be as much as possible implemented in the general care

provision for other service users, e.g. other persons in need of medical care,

congenitally handicapped persons, the elderly, etc. Based on this vision it was decided to

transfer the “medical” component of mental health care from AWBZ to

ZVW (health care sector);

transfer the “public” component of mental health care from AWBZ to

WMO (social care and welfare);

transfer the financing of forensic psychiatry from AWBZ to the

Department of justice (see further).

An important additional change compared to previous policy periods is the introduction

of a national provision of curative ambulatory mental health care (given the introduction

of private health insurance), while in previous periods it was limited to regional

provision.

From January 1 st 2008 on, the medical component of mental health care is transferred

to the health care sector, at least for the first year of care; 75% of mental health care

budget currently goes to the field of the ZVW wwwwww . After one year, reimbursement is

transferred to the domain of AWBZ; about 25% of mental health care budget currently

still belongs to the responsibility of the AWBZ. Social support still remains limited to

2% of the mental health care budget (it should be noted that it is difficult to know if this

budget is spent to social support of persons with mental disorders, since the budgets

transferred to the municipalities are not earmarked). At the same time, DBC’s are

introduced in mental health care (see further).

In principle, specialist mental health care including ambulatory consultations of

psychiatrists, is only accessible to people referred by their GP. In both acute and crisis

situations, secondary level mental health services can be contacted directly. According

to Trimbos, an evolution towards a more intensive collaboration between the first and

second mental health care line can be noted, (partly) due to specific governmental

stimuli. However, this has not diminished the amount of referrals to secondary care (cfr

Trimbos Trendrapportage GGZ 2008 p127) 207 . As from 1 st January 2008, psychologists

can provide first line psychological help and this is considered to belong to the insured

standard benefits package xxxxxx that also includes e.g. consultations by general

practitioners (see further).

Because the recently introduced market-oriented principles require that every citizen

should be able to compare yyyyyy different care organizations, efforts are put in the

development of performance indicators, e.g. the existence of (long) waiting lists zzzzzz . No

information on a generally applicable system could be found. Specific programs on

quality evaluation are also being developed (e.g. the KRAS project on schizophrenia care

by the Trimbos institute).

wwwwww http://www.minvws.nl/kamerstukken/cz/2008/aanbieding-van-de-trendrapportage-ggz-2008.asp

xxxxxx www.nza.nl

yyyyyy http://www.kiesbeter.nl/zorgverleners/

zzzzzz http://www.ggznederland.nl/index.php?p=116852


128 Evidence Based Mental Health Services KCE reports 144

9.4.4 Scientific institutes, Knowledge centers for mental disorders

The Trimbos institute aaaaaaa is a national institute in charge of the development of new

treatments, guidelines and prevention programs in mental health. It is also responsible

for evaluation of the Dutch mental health care system, including effectiveness, quality

and accessibility; and it has the responsibility to inform the Dutch Government on these

subjects. It is in charge of education and support of mental health care professionals.

ZONMw bbbbbbb , the Dutch Organization for health research and development, is a

national organization that promotes quality and innovation in the field of health research

and health care, initiating and funding new developments. ZonMw also actively

promotes knowledge transfer and implementation. ZonMw acts as an intermediary

between policy, research and practice. It has a specific subdivision for mental health

care.

“Knowledge centers” are centers comprising one or more mental health care

organization as well as research centers such as university hospitals or the Trimbos

institute. Together they aim at providing specialized information on a specific target

group of patients to other professional institutions, and they aim at organizing research.

Many different “Knowledge centers” for mental health care exist ccccccc , e.g. a knowledge

centre for bipolar disorders, schizophrenia, elderly persons, autism, informal care giving

etc. The Knowledge centers are centralized on the national level in the “Landelijk

netwerk kenniscentra GGZ”. In 2003, 7 knowledge centers were officially recognized

and subsidized by the Government (Brancherapport GGZ 2000-2003, Trimbos).

9.4.5 Mapping of existing services

9.4.5.1 A Dutch definition of residential, partial/mixed residential and ambulatory care

As a preliminary remark, it is interesting to note that the GGZ Nederland ddddddd (an

organisation of Dutch mental health care providers) has developed operational

definitions to classify clients as ambulatory, partially residential or residential.

• Residential clients: when clinical inpatient care takes 90% or more of the total

care

• Partial residential care: if clients receive less than 90% clinical care

• Mixed residential: if clients receive less than 90% clinical care and if the client

receives any other form of support.

• Ambulatory: care outside the clinical facilities.

The main characteristic of this definition is that the demand side, and not the supply

side, is taken as a reference point.

9.4.5.2 The “Service Tree” in the Netherlands: (still) integrated mental health care

facilities.

In the description of the other countries, we use the ‘Service Tree’ developed by

Johnson et al. to map the mental health services 5 . This ‘Tree’ is presented in the Table

below.

A table with an overview of available services in the Netherlands is presented in chapter

14.1.6.

aaaaaaa http://www.trimbos.nl/

bbbbbbb http://www.zonmw.nl/nl/

ccccccc http://www.trimbos.nl/ggz-adressen/kenniscentra

ddddddd http://www.ggznederland.nl/


KCE Reports 144 Evidence Based Mental Health Services 129

Table: Synthetic presentation of the ESMS tree

SECURE (1)

RESIDENTIAL Generic acute Hospital (2)

Non-hospital (3)

Non-acute Hospital (4) Time limited (4.1)

Indefinite stay (4.2)

Non-hospital (5) Time limited (5.1)

Indefinite stay (5.2)

DAY & STRUCTURED Acute (6)

ACTIVITY

Non-acute (7) High intensity (7.1)

Low intensity (7.2)

OUT-PATIENT & Emergency care (8) Mobile (8.1)

COMMUNITY

Non-mobile (8.2)

Continuing care (9) Mobile (9.1)

Non-mobile (9.2)

SELF-HELP & NON-PROFESSIONAL (10)

However, as already mentioned, the Dutch mental health care model used till recently

to a certain extent a different organisation typology eeeeeee .

During the 1990’s, in most of the Dutch regions, psychiatric hospitals, Riaggs (see infra)

and other types of care provision merged into so-called “integrated mental health care

facilities”. These “integrated mental health care facilities” offer a spectrum of services in

ambulatory, residential or semi-residential form. No specific information is readily

available e.g. on the total number of places in semi-residential care, which makes it

impossible to use the “Service Tree”.

Nevertheless, some general information on the distinctive care settings in the

Netherlands is available in the Table 9.1. (Note that the Netherlands have a population

of about 16 million inhabitants). Even though the most recent reformations (see above)

without doubt will influence the organizational system and change it again, the current

situation is still largely influenced by the existence of “integrated mental health care

facilities”.

Table 9.1 Number and type of Mental Health Care Organizations (GGZinstellingen),

2000-2005

2000 2001 2002 2003 2004 2005

Integrated mental health care

30 32 35 39 41 40

facilities*

Psychiatric hospitals (APZ,

Algemeen psychiatrische

ziekenhuizen)

12 10 8 5 3 3

RIAGG 19 15 12 12 10 9

RIBW 26 24 24 23 21 21

Facilities for child and adolescent

psychiatry

10 10 10 10 10 10

Integrated facilities for addiction

care

12 12 11 9 8 9

Facilities for ambulatory addiction 8 8 9 9 6 4

care

Forensic psychiatric centres (TBS

“Ter Beschikking Stelling”)(Dep.

Justice)

7 7 7 7 7 7

Total 124 118 116 114 106 103

Source: Leden Administratie GGZ Nederland 2006

PS. *Additionally, independent psychiatric departments are found in 40 general hospitals in 2006

(Trendrapportage 2008 Part 2 p7) 207.

eeeeeee http://www.ggznederland.nl/index.php?p=115302 (in Dutch)


130 Evidence Based Mental Health Services KCE reports 144

A general distribution of ambulatory, semi-residential and residential care for the

different care circuits is also available (Table 9.2). This should be read cautiously: all

types of care, also ambulatory short-term care are included, for which no numbers are

mentioned in the description of several other countries.

Tabel 9.2 Care type for each circuit (including integrated mental health

care facilities**, psychiatric hospitals (APZ), RIAGGs***, RIBW and child-

and adolescent psychiatry), 2006, in%.

Children

and

adolescents

Adults Elderly Sheltered

Living*

Total

Ambulatory 96 86 88 46 88

Part-time 1 2 2 0 2

Residential 2 8 7 53 7

Mixed residential 1 4 3 1 3

Total 100 100 100 100 100

Source: Trimbos Trendrapportage2008 part 2 (p 25) 207

*In independent RIBWs or in RIBWs within integrated care facilities

**PAAZ (psychiatric departments of general hospitals not belonging to integrated mental health

care facilities) are not included.

***Consultations of independently working psychiatrists and psychologists are not included; GP

consultations are not included.

Although for the Netherlands it impossible to use the “Service Tree”, in the next

paragraph some additional information will be given for some types of services, for

which this is necessary to understand properly the Dutch situation.

9.4.5.3 Inpatient services

Official numbers estimate that in 2007 in the Netherlands 13.7 psychiatric beds were

available per 10 000 population fffffff . This number does not differentiate between hospital

beds in integrated care facilities; beds in psychiatric hospitals; or psychiatric services in

general hospitals. The number is among the highest in Europe. The residential mental

health care capacity stabilized in the 1990’s, but since the beginning of the new century,

there is again an increase (Trendrapportage 2008 Part 1) 207 . From 1993-2006 there was

a net stabilization of the residential capacity taking into account the population growth;

so no “deinstitutionalization” took place. When the Sheltered housing schemes (see

further) are included as well, the residential care and housing services currently take

about 50% of the total mental health care budget ggggggg .

The Trimbos institute estimates that this is caused by several influences. First of all,

these “residential beds” include several types of service provision, which are not always

true residential care, but which for administrative reasons are coded under

“residential”. Secondly, the fact that for a long time mental health care, although

internally integrated, had an isolated position in the society and was poorly integrated in

other cure and care service provisions (“verkokering”), made it necessary to establish

housing schemes within the mental health care circuit as well.

fffffff HFA-Database (http://data.euro.who.int/hfadb/ ) shows 134 Dutch Psychiatric hospital beds per 100000 in

2004 and 137 in 2007. HFA-DB definitions are World Health Organization Definitions harmonized with

EUROSTAT and OECD in 2006: Psychiatric care beds in hospitals (HP.1) are hospital beds

accommodating patients with mental health problems (part of HC.1 in the SHA classification). Inclusion -

All beds in mental health and substance abuse hospitals (HP.1.2). - Beds in psychiatric departments of

general hospitals (HP.1.1) and of speciality (other than mental health and substance abuse) hospitals

(HP.1.3). Exclusion - Beds allocated to non-mental curative care (part of HC.1). - Beds allocated to longterm

nursing care in hospitals (HC.3). - Beds for rehabilitation (HC.2). The data cover beds in mental

hospitals and, since 1990, includes beds in psychiatric departments of general hospitals. Statistics

Netherlands: Statistics of intramural health care. Beds in university hospitals excluded as from 2002

onwards.

ggggggg http://www.minvws.nl/kamerstukken/cz/2008/aanbieding-van-de-trendrapportage-ggz-2008.asp


KCE Reports 144 Evidence Based Mental Health Services 131

Nevertheless, the currently existing housing facilities for persons with mental disorders

are largely “deconcentrated” and often organized in small living units, not resembling

anymore the ancient asylums. Finally, according to Trimbos, the stable and infinite

AWBZ resources (provided care would be reimbursed anyway), the fact that politicians

did not put forward firm goals for deinstitutionalization, and the high number of e.g.

psychiatric nurses in the Netherlands, might have had an influence as well.

Psychiatric hospitals

The Dutch “psychiatric hospital” (PH) (in 2005, only 3 independent PH were left)

encompasses a very wide range of services that are not all residential, the “integrated

mental health care facilities” alike. Psychiatric hospitals have admission wards and

specialized units for groups with special needs (e.g. people with addiction problems),

psycho-geriatric departments for the elderly; but they also developed outpatient clinics,

day centres, housing units for long-term residents, therapeutic communities, intensive

home care, outreach activities.

Psychiatric wards in general hospitals

General hospitals can have a psychiatric department for (acute) psychiatric treatment

(PAAZ). After the merging of different mental health care organisations a vast majority

of these psychiatric wards of general hospitals became part of integrated mental health

care organisations. In 2006, about 40 independent PAAZ existed.

Regional institutes for Sheltered housing schemes

RIBW (Regionale Instelling voor Beschermende Woonvormen), or the “integrated

mental health care facilities” they belong to, organise different forms of staffed living

facilities. Different forms of housing facilities are offered, varying from individual to

group facilities. In 2006, 10.225 places were available or 64 places/100.000 population

(Trendrapportage 2008 part 1 p66; part 2 p59) 207 . There were 74 users/100.000

population in 2004. However, RIBW also offer different forms and models of

independent living support & coaching hhhhhhh for people living alone iiiiiii . They also offer

day activities and are in charge of help to those who want to go back to work (see

further).

Many of the RIBW fused with one of the large integrated mental health care facilities.

Psychiatric nursing facilities

Psycho-geriatric nursing-homes are in particular oriented on the old age population.

Forensic psychiatry

A special “care circuit forensic psychiatry” is developed for persons with a mental illness

having committed a criminal offence. Care programs aims at treating the disorder of the

client and protecting society for other offences. They contain a wide range of services,

from a stay in a closed ward to supervised forms of independent living. It always holds

obligatory mental treatment.

Three types of inpatient services are distinguished:

• forensic psychiatric centres (FPC) for people under terbeschikkingsstelling

(tbs) (the heaviest profiles) These facilities are generally highly protected.

• forensic psychiatric hospitals (FPK)

• forensic psychiatric departments (FPA) with closed and open units.

Treatment in FPA is generally shorter than in FPK.

FPC is generally fully under the responsibility of the department of Justice; FPK and FPA

are part of the regular mental health care (although they are funded through the justice

department). Because of the problems of continuity of care, forensic policlinics have

been created, as part of the forensic circuits.

hhhhhhh http://www.ribwalliantie.nl/default.asp?p=wb&m=menu_Woonbegeleiding

iiiiiii http://www.ribwalliantie.nl/ (Dutch)


132 Evidence Based Mental Health Services KCE reports 144

9.4.5.4 Ambulatory services

Most of these services also belong to the “integrated mental health care facilities”; some

services remained independent (see Table 9.1 in chapter 9.4.5.2)

Regional institutes for ambulatory mental health

Riaggs (Regionaal Instituut voor Ambulante geestelijke gezondheidszorg) offer a broad

spectrum of services from curative psychotherapy to supportive community psychiatric

care for different age groups (children, adults elderly). They have the responsibility to

organize a permanent outreach crisis service. The Trendrapportage 2008 (part 2 p 57-

59) 207 mentions 4100 users/100.000 population (20-64 years) or 5427 users/100.000

population (+18 years) of ambulatory care in 2004 (RIAGGs and out-patient clinics

included, independently working psychiatrists or psychologists are not included).

Regional institutes for sheltered housing schemes

RIBW (Regionale Instelling voor Beschermende Woonvormen, see higher), or the

“integrated mental health care facilities” they belong to, offer different forms and

models of independent living support & coaching jjjjjjj for people living alone kkkkkkk , in which

case therapeutic medical care is not offered. More and more outreach teams are

developed to support clients living in regular housing. They also offer day activities and

are in charge of help to those who want to go back to work. However, no information

on the number of vocational rehabilitation services or programs for supported work is

available (cfr Trimbos Trendrapportage GGZ 2008 p76).

Day hospitalization (Partial hospitalization)

Partial hospitalization places are developed as alternatives to full time-hospitalizations. It

are mainly day-hospitalisations in psychiatric departments of general hospitals. In 2005

there were 5124 places for part-time hospitalization (over-all population,

Trendrapportage 2008 part 1 p75); this is approximately 32 places/100.000 population.

This means an increase by 300% since 1980. Part-time hospitalization or other forms of

part-time treatment were used by 230 adults (20-64 years) in 2004 (Trendrapportage

2008 part 2 p60) 207 .

Day care

Day care facilities are developed in the framework of RIBW lllllll . Activities can be

oriented towards structured day activities or voluntary work adapted to the condition

of the patient. Most of these day care centres are an integrated part of other mental

health care organisations. The use of day care centres is most of the time integrated in

the programmes of long term care. No precise numbers of capacity or users of these

services were found; according to the Trendrapportage 2008 there were 125 day

centres and about 100 services for vocational rehabilitation in 1998.

Rehabilitation centres

Several forms of rehabilitation services have been developed during the 1990’s, including

consumer run self help projects (e.g. work, restaurants, buddy projects, club houses,

sporting groups, day meeting centres, information and help desks etc.

Independently working mental health care providers

To the independently working mental health care providers belong psychiatrists (second

line health care professionals), and psychologists (first line health care professionals). In

2005, there were 2487 practisizing psychiatrists in the Netherlands, or 15.5/100.000

population (Trendrapportage 2008 part 1 p56) 207 . No further information of the

subgroup of independently working psychiatrists, or on their activities was found.

Trendrapportage does not comment on the number of psychologists, because many are

working in other sectors than mental health care.

jjjjjjj http://www.ribwalliantie.nl/default.asp?p=wb&m=menu_Woonbegeleiding

kkkkkkk http://www.ribwalliantie.nl/ (Dutch)

lllllll http://www.ribwalliantie.nl/default.asp?p=dw&m=menu_Dagbesteding%20&%20werken (Dutch)


KCE Reports 144 Evidence Based Mental Health Services 133

9.5 FINANCING OF MENTAL HEALTH CARE

9.5.1 Global data

According to the WHO, about 7% of the Dutch health care spending is used for mental

health care (2005) mmmmmmm .

According to CBS estimates (Trendrapportage Trimbos, 2008 part 1 p80) 207 specialised

mental health care accounted in 2007 for 6,1% of all health care costs nnnnnnn . The public

expenditures for mental health care have increased in the years 1998-2007 (99%), even

more than the increased expenditure in general health care (81%). In 2005 intramural

facilities and facilities for sheltered living accounted for 56% of the mental health care

budget (the former for 45%, the latter for 10%); and part-time or day care treatment

for 12%. Ambulatory care accounted for 32%, of which about 1% is for independently

working psychiatrists; GPs and psychologists in primary care are not included.

Some regional differences are described, as some provinces spend relatively more on

ambulatory care provision, and others more on residential forms of care. These

differences are not explained by epidemiological factors, but mainly through historical

factors.

9.5.2 Data per sector of activities

Until the reforms of 2006 the mental health care sector was identified as rather

homogenous with an earmarked budgeting through the AWBZ (see 9.4.3). The

Trendrapportage GGZ 2008 hypothesizes that the earmarked and clearly identified

financing of mental health care is probably an important factor that contributed to the

development of an identifiable and integrated health care sector.

However, criticisms had grown, mainly because mental health care services were

integrated with other mental health care services but not with regular cure and care

service provisions for other disorders (“verkokering”). This led to an isolated position

of mental health cure and care, and also of its patients; and it also gave the large care

providers (too) much influence and the patients too little freedom of choice. Moreover,

it was felt that the “treatment” of mental disorders belongs to the field of medical care

and the ZVW, and it was stressed that this type of care often does not correspond to

the field of AWBZ. At the same time, in the ZVW large reforms had started under the

credo “Less government, more market”, and it was hoped that the same reforms in the

field of mental health care would lead to more efficiency and less costs.

The most recent policy reforms in the Dutch mental health care system date from

2006, and take as a starting point that mental health care should be part of a network of

other (health) care and welfare facilities.

As a consequence of these reforms, as of January the 1 st 2008, the medical component

of mental health care and 75% of the former mental health care budget has been

transferred from the public AWBZ to the private sector of ZVW; and first line and

specialist medical secondary line is funded and reimbursed within the framework of the

ZVW (zorgverzekeringswet). After one year, the patients will again fall under the

AWBZ regime, and about 25% of the mental health care budget still belongs to the

responsibility of the AWBZ. The funding of forensic care has been transferred to the

justice department.

mmmmmmm http://www.who.int/mental_health/evidence/mhatlas05/en/index.html

nnnnnnn This includes expenditure for psychiatric consultations outside the care facilities, and of psychotherapist

consultations, which each account for 1% of the total mental health care budget.


134 Evidence Based Mental Health Services KCE reports 144

For hospital and specialist mental health care under the ZVW, an adapted DRG funding

system (“diagnose-behandel combinaties”, DBC’s) has been introduced

(http://www.dbconderhoud.nl/ ). As from 1 st January 2008, psychologists can provide

first line psychological help and this is considered to belong to the insured standard

benefits package that also includes e.g. consultations by general practitioners; for this

type of service no DBC has to be registered. Even so for care that is considered to fall

under the AWBZ, no DBC has to be registered ooooooo .

Each DBC describes the trajectory of care and the related activities based on the needs

of the patient. Based on these trajectory related activities and interventions, the cost

are estimated. The costs are estimated on the number and hours of interventions and

the staff needed. So far, if finally the number of hours or interventions exceeds the

estimated number, the difference is adjusted for. This leads to the informal critics that

the DBC system in fact is a fee-for-service system.

The DBC logic has integrated the clinical (intramural) and ambularory interventions in

one common model ppppppp , but distinguishes “verblijfsgroepen” (residential groups)

from “behandelgroepen” (treatment groups) for setting the tariffs. No specific

identification for multidisciplinary acts exists yet. Currently there are 145 treatment

groups (based on the DSM-IV categories) and 70 residential groups. The implementation

of the DBC in mental health care (and other care) has not been easy. It is at this stage

too early to assess the impact of the new financing regime.

Within AWBZ the financing is based on “intensity of care” (zorgzwaartefinanciering)

since January 1st 2008. The financing principles will be based on the needs of the clients,

replacing an average funding per bed. Different “intensity of care packages”

(zorgzwaartepaketten) for mental health care have been identified qqqqqqq

The provision of support under the WMO (as from 2007), is expected to contribute a

small fraction of the budget to persons with mental disorders. However it is expected

that in the future this fraction of WMO budget for mental health care could increase, as

many local policy makers were not ready to provide the necessary support for persons

with mental health care problems (especially for the part of providing day-care and

autonomous living arrangements). A first preliminary report of this shift offers

indications that the transfer of AWBZ activities to WMO activities is quite a difficult

issue (Trendrapportage 2008 GGZ) 207

In 2009 the Minister announced his intention to lower tariffs for mental health

treatment by 3.5 percent next year, because GGZ members overspent by EUR 185

million in 2008. Lower tariffs would mean less income for the GGZ member

institutions.

ooooooo http://www.dbcggz.nl/website/faq.asp?id=50&command=detail&questionid=25&questionnr=9

ppppppp http://www.dbcggz.nl/cms/data/attachments/505/bestand/Productstructuur%202008.pdf

qqqqqqq http://www.minvws.nl/kamerstukken/lz/2006/voortgangsrapportage-zorgzwaartefinanciering-

2.asp


KCE Reports 144 Evidence Based Mental Health Services 135

9.6 ADVANTAGES/DISADVANTAGES OF THE DUTCH

MENTAL HEALTH CARE ORGANIZATION

• The Netherlands are clearly ahead in the creation and establishment of care

programs, since already in the 1990’s they emphasized the importance of

continuity of care. Currently 60% of the mental health services use Care

programs. However, no official documents were found on the quality of these

care programs, their outcome (do they increase efficiency and/or quality of

care?), nor on their appreciation by patients and care providers.

• The Netherlands are also ahead in providing integrated mental health care

circuits in large, fused care companies. This might have (partly) been

facilitated by the uniform funding system (the AWBZ). A possible drawback is

that it might not be easy to get information on the availability of some specific

types of care provision, e.g. work-related rehabilitation, partly because the

way it is organized might differ from one care provider to another.

• Notwithstanding its advantages, the integrated care circuits have been

criticized for not providing enough choice to their patients, and for being not

open enough to the rest of the society (“kokerzorg”). So the system has to

change again, and recently new financial stimuli were created aiming at

optimizing the system. E.g. a certain amount of money goes directly to the

municipalities, who should be able to coordinate and provide social support

directly in the community for all types of social needs. However, since this

budget is not earmarked, it will depend on each municipality whether they

estimate that persons with mental disorders need the money the most (or

not). According to Trimbos, regional inequalities might arise.

• As from January 1st 2008, 75% of the mental health care budget falls under

the responsibility of the ZVW (Zorgverzekeringswet). The recent marketoriented

development of the ZVW uses a DRG-like system (DBC’s) for its

funding, which are based on DSM-IV categories and represent actually a

certain type of fee-for-service system since professionals are paid for a

number of minutes of care provision. The market-oriented system should

regulate excesses. Whereas indirect care (no direct care with the patient, e.g.

writing reports) is counted separately, no specific item for multidisciplinary

consultation so far exists.

• However, the system, including the DBC system, appears to be quite

complicated and difficult to implement. This led already to the informal use of

a new word, “care in the office” (“kantoorzorg”), since the administrative

burden seems to take so much time that less time is left for contact with

patients.

• After one year, patients fall under the responsibility of the AWBZ. The

AWBZ has an independent agency responsible for indication setting (CIZ); its

funding is based on functioning of the disabled person and the reimbursement

is adjusted to the intensity of care that has to be provided

(zorgzwaartefinanciering). This is much the Flemish VAPH (Vlaams agentschap

voor personen met een handicap) alike, but the VAPH is not competent for

reimbursement of persons disabled because of a mental disorder (except for

persons with a congenital mental disorder, mainly autism). Rather, the Belgian

federal NIHDI (National institute for health and disability insurance,

RIZIV/INAMI) is in charge of a large part of this care. The Dutch AWBZ

funding system so far has not been officially been evaluated on its merits and

its weaknesses.


136 Evidence Based Mental Health Services KCE reports 144

• The Trimbos institute is quite critical for the reformations of the last few

years, and especially concerning cure and care for persons with severe and

persistent mental disorders. Trimbos fears that the market-oriented system

will somehow invest less in care needs of these persons, because it is

complex and therefore not easy to manage. Also, the market- and for-profitprinciple

might disturb the sense of collaboration that currently exists. On

the other hand, the budget for the AWBZ will diminish, and the WMO

budget is not earmarked.

• From 1993-2006 there was a net stabilization of the residential capacity

taking into account the population growth; so no real “deinstitutionalization”

took place (for Trimbos interpretation, see before). Rather a

“deconcentration” took place, i.e. an evolution to different types of smallscale

housing initiatives instead of the large asylums.

• In the Netherlands, general practitioners are the gatekeepers to specialized

mental health care (except for urgencies). According to Trimbos, an

evolution towards a more intensive collaboration between the first and

second mental health care line can be noted, (partly) due to specific

governmental stimuli. However, this has not diminished the amount of

referrals to secondary care. (cfr Trimbos Trendrapportage GGZ 2008

p127) 207 . Psychologists can provide first line psychological help and this is

considered to belong to the insured standard benefits package of the ZVW.

• Care improvement and knowledge dissemination is stimulated by the

Government by the funding of scientific institutes and knowledge centers.

Performance indicators are under development.


KCE Reports 144 Evidence Based Mental Health Services 137

10 SPAIN

10.1 LITERATURE SEARCH: METHODOLOGY

See general methodology. No information (references, data…) has been included after

August 31, 2009.

10.2 ORGANIZATION AND FINANCING OF THE HEALTH

CARE SECTOR rrrrrrr

The level of health care coverage is nearly universal in Spain. After the introduction of

the NHS in 1986, the eligibility is increased to cover most of the population. By 1997, it

was estimated that 99,7 % of the population was covered by the statutory system: 94,8

% of the population was covered by a obligatory affiliation to the social security system,

the vulnerable and disadvantaged were subject to separate administrative regulations

and the remaining 4,6 % of the population (2 000 000 people) were covered through

three non-profit mutual funds (Social Institute for the Armed Forces – ISFAS, the

General Legal Mutual Company – MUGEJU and the Mutual Fund for State Civil Servants

– MUFACE) 209 .

10.2.1 Organizational overview of the health care system

In 2009, it was estimated that Spain had about 46.6 million inhabitants sssssss . The political

organization of the Spanish state is made up of the central state and 17 highly

decentralized regions (Autonomous Communities, AC) with their respective

governments and parliaments. Central government has the responsibility for promoting

coordination and cooperation in the health sector. From 1986, the transition to a

National Health system (NHS) has transformed the financing system into a system

based on taxes with almost universal coverage. The decentralization was completed in

2003 and resulted in 17 ACs being responsible for provision and financing of health care

in their territories.

10.2.1.1 The role of the central government

The central government in Spain assumes responsibility for certain strategic areas,

including (Duran, 2006, p. 21) 208 :

• general coordination and basic health legislation;

• financing of the system, and regulating the financial aspects of social security;

• definition of a benefits package guaranteed by the NHS;

• international health;

• pharmaceutical policy;

• undergraduate education and postgraduate medical training;

• civil service-related human resources policies.

10.2.1.2 The role of regional governments

Each region holds health planning power as well as the capacity to organize its own

health services to the level of decentralization that it considers most appropriate. Since

2001, the co-responsibility between the central state and the regions has increased and

since January 2002, all regions have received the same management power within the

National health system.

rrrrrrr We base this section on the report on the Spanish health care system ‘health System in Transition’ N°4

(2006) 208

sssssss http://www.ine.es/prensa/np551.pdf


138 Evidence Based Mental Health Services KCE reports 144

10.2.1.3 Health areas

According to the 1986 General Health Care Act, health areas are defined according to

geography, socioeconomic standards, demography, employment, epidemiological

factors, cultural concerns, transportation and the existing health facilities. Each health

area, responsible for the management of facilities, benefits and health service programs

within its geographical limits, should cover a population of no fewer than 200 000

inhabitants and no more than 250 000. Both primary health care and specialized care

services are provided in the health areas. Primary health care is defined as care of

individuals, families and the community at large through health promotion programs,

prevention, curative care, and rehabilitation. Within specialized (outpatient and

inpatient) care, each health area is linked to, or has, at least one general hospital.

Specialized ambulatory care is provided through an integrated public network, which is

dependent on hospitals, and in some cases staffed with the same teams (with members

who rotate to cover ambulatory visits).

10.2.1.4 Basic health zones

Basic health zones are the smallest units of the organizational structure of health care.

Each is defined in accordance with the degree of concentration of the population, the

epidemiological characteristics, and the facilities and health resources of the area. A

maximum distance of 30 minutes between communities and the location of services, as

standard traveling time, gives rise to basic health zones covering between 5000 and 25

000 inhabitants. They are usually organized around a single primary care team, which is

also the main management unit of the zone, coordinating prevention, promotion,

treatment and community care activities. 2498 basic health zones have been designed,

within which the resources of PHC are organized and the corresponding health centers

deliver care to the local population. The leader (termed “coordinator”) of the EAP

(Primary care team) reports to the area manager while simultaneously holding a direct

line of accountability to regional government authorities (which reflects the limited

managerial autonomy given to health care areas). The governance structure in hospitals

is made up of a medical division, a nursing division and an administrative division, all

hierarchically subordinated to the general manager, who directly reports to the

corresponding regional authorities. This management system was created through

central legislation during the 1980s. The autonomous communities, however, are free

to modify this organizational model, and to choose a higher or lower degree of

decentralization of power within their respective territories.

10.2.2 Financing of the health care sector

In the mid-1970s, the social security system covered about two thirds of the total health

care expenditure. The transition to a National health system (NHS), initiated in 1986,

led to an important shift from the social security to contributions of the State. The new

model of financing was adopted in 2001 with two main sources for the Autonomous

Communities (ACs): taxes and allocations from the central government. Private health

care financing consists of three complementary sources of finance: out-of-pocket

payments to the public system, out-of-pocket payments to the private sector and

voluntary health insurance 208 .

Table 10.1: Sources of revenue as a percentage of total expenditure on

health (comparison 1991 – 2003). Source: European Observatory 208

Source of revenue 1991 2003

Public 77.5 71.2

Government (central + regional) excluding social security funds 55.7 65.9

Social security funds 21.8 5.3

Private sector 22.5 28.9

Private insurance enterprises (other than social insurance) 2.9 4.3

Private household out-of-pocket expenditure 18.7 23.7

All other private funds 0.9 0.8


KCE Reports 144 Evidence Based Mental Health Services 139

Health care expenditures accounted for approximately 8,3 % of the GDP in 2005. 71,2

% of total health care expenditure is publicly funded, of which taxation accounts for 98

%, while private expenditure through user charges is approximately 24 % and private

insurance just 4 % of the total health care expenditure (OCDE ECO HEALTH 2007 and

Salvador-Carulla et. al. 2006 209 ). Out of pocket spending makes up the most important

part of the private spending 210 with a proportion of 74 %.

92,2 % of the total public health expenditure (estimation for 2006: 46,400 Million euro)

is directly managed by the ACs. The complement is represented by transferred funds

from the central government to the ACs 209 .

Key points

• The Spanish system is a NHS-type system for which funding is largely

provided by taxes and allocations from the central government. However,

private financing is also provided by out-of-pocket payments and voluntary

complementary insurance.

• Mapping of mental health care supply is organized on a “basic health zones”

system (5000-25 000 inhabitants). Each basic health zone is organized

around a primary care team.

• The basic health zones belong to a larger Health area (200 000 to 250 000

inhabitants) that is responsible for both primary and specialized health care

and has at least one general hospital.

• Given the Spanish institutional and political structure, practical organization

of psychiatric care also depends on the 17 highly decentralized regions or

AC’s (“Autonomous Communities”).

• 92 % of the total public health expenditure is directly managed by the AC’s.

The rest are funds transferred from the central government to the AC’s.

10.3 ORGANIZATION OF THE MENTAL HEALTH CARE IN

SPAIN

Mental health care has traditionally been one of the most neglected aspects of the

Spanish health system. Historically there has been a pronounced over reliance on

hospitalization for chronic psychiatric cases, inadequate provision of outpatient care and

a notable lack of social health care resources. The system was characterized by an

excess of division of responsibility for services among various public administration

bodies and a lack of coordination among parallel networks providing care in this field. In

the 1970s, several mental health care teams in some provinces began to promote on

their own initiative a community-centred approach to mental health care, creating

special units in contrast with the existing psychiatric hospital-centred mental health

network (Duran, 2006, pp. 139-140) 208 .

10.3.1 The ‘psychiatric reform’

The Spanish ‘psychiatric reform’ presents a specific profile because it coincided with the

democratic transition that took place in the country in the 1970s and 1980s.

Following Pinto 2002 (pp. 24-25), the conceptual bases of the reform can be

summarized as follows 211 :

• to guarantee attention to mentally ill patients within the general network of

health care and especially in primary care services;

• to redefine the therapeutic meaning of psychiatric hospitalization, which lost

its central role in psychiatric care, and was located in general hospitals

• to provide adequate community services and social support to make it

possible to rehabilitate and resettle psychiatric patients in society

• to bring about changes in the community to prevent the marginalization of

these patients

• to guarantee the civil rights of persons with mental disorders


140 Evidence Based Mental Health Services KCE reports 144

Considering these aims, the closure of mental hospitals had to be considered as the

consequence of the changes advocated in psychiatric care. Between 1982 and 1985,

number of initiatives was taken by the central government and by the autonomous

communities. In 1983, the Commission on psychiatric reform was created and in April,

1985 a report establishing the conceptual bases of the reform was edited. The General

Health Care Act (1986) confirmed that mental patients should be treated as users of

worth equal the rest of the population.

10.3.2 General principles

In accordance with the principles of the Spanish General Law on Health, the psychiatric

services should be organized according to the ‘Health Areas’ covering between 200 000

and 250 000 inhabitants ttttttt . They should also provide a fully integrated mental health

care per area.

Access to psychiatric services should be through primary care units, with the specialized

levels of care based on community mental health centres. Hospitalization, which is now

considered merely one more instrument in the therapeutic process, should be provided

by general hospitals. Also considered of specials importance is the need to complement

psychiatric care by providing sufficient “intermediate” community services (day

hospitals, day centres, units of psychosocial rehabilitation, sheltered

accommodations,…). The plan was that all these resources should constitute a

functional unit that will allow an integrated approach to the treatment and rehabilitation

of patients and to the prevention of mental illness.

10.3.2.1 Hospital care

The reduction in the number of beds in psychiatric hospitals varied considerably among

the different autonomous communities. Initially, only a few general hospitals had

psychiatric units. However, after 1986, following the recommendations of the

commission's report on Psychiatric Reform, there was a significant increase in the

number of these units, which started to assume responsibility for the acute inpatient

care of mental illness. In 1990, there were 74 such units with a total of 1,784 beds, and

in 1995 there were 105 units with 2,401 beds; since 1995 this reduction has slowed

down (Vazquez-Barquero 2001) 212 . Also, the number of psychiatrists increased

significantly during the Psychiatric Reform and reached 2,016 in 1994 (5.1 per 100,000

inhabitants). Again, there are marked differences between the different autonomous

communities. The number of psychologists has risen even more and the same is true for

qualified nurses (Ministerio de Sanidad, 1999).

10.3.2.2 Primary care

Extending mental health care to primary care has been one of the mainstays of the

Psychiatric Reform. The referral rates from primary to specialized care are around 11

percent and the capacity to provide treatment is 89 percent, which shows the

importance of the role played by primary care in mental illness. While the integration of

mental health care in primary care generally has been considered to be beneficial,

questions have been raised as to the difficulty that general health professionals tend to

have in understanding some specific aspects of mental illness and its treatment (e.g.

treatment not belonging to the traditional medical-biological model) (Vazquez-Barquero

2001) 212 .

ttttttt We base this section on the work of Pinto 2002 211.


KCE Reports 144 Evidence Based Mental Health Services 141

10.3.2.3 Secondary care in the community

Mental health centers or teams, created following the criteria of territorial distribution

and decentralization, are the cornerstone of the specialized mental health care. They

have experienced the greatest growth due to the Psychiatric Reform (see Appendix to

chapter …). They all have a minimum basic staff consisting of a psychiatrist, a

psychologist, a qualified nurse, and a person to perform administrative duties.

Notwithstanding this, they are distributed unevenly throughout the country and their

resources also vary considerably from one AC to another. In 1996, 555 mental health

centers existed (477 in 1991) with an average coverage rate of 70 757 inhabitants per

centre (79 061 in 1991) and a utilization rate of 92 annual visits per 1 000 inhabitants

(53 in 1991) (Duran, 2006, pp. 143-144) 208 . There has also been a clear change in the

pattern of use of these mental health services, with an increase in the demand

concerning minor psychiatric disorders and a greater similarity in the sociodemographic

characteristics between users of these services and users of the other

medical specialties.

10.3.2.4 Intermediate care services

10.3.2.5 Conclusion

The health reform has included the transfer of some services for people with mental

disorders and for those with intellectual disabilities out of the health sector and usually

to the social care sector. Such service transfers include non-hospital residential care,

occupational care and other intermediate care facilities. These “intermediate”

community services have been developed, but this happened to a greater extent

precisely in those communities which have taken de-institutionalization and the closure

of psychiatric hospitals furthest. Also, it has been observed that the most important

difficulty of the “psychiatric reform” has been the development of intermediate

community services and programs to rehabilitate and resettle patients in the community

(Vazquez-Barquero 2001) 212 . As a consequence of this, at the end of the 1990s about

90% of mentally ill patients in Granada or Santander were living with their families (as

compared to about 50% in England, the Netherlands and Denmark). Although there

might be many other causes for this phenomenon as well, this situation generates high

levels of family burden that, according to Vazquez-Barquero et al, are not compensated

by appropriate family support programs.

It can be concluded that the ‘psychiatric reform’ initiated since the 1980s has produced

significant achievements (Pinto, 2002, p. 24) 211 :

• the development of a new organizational structure for mental health care,

decentralized in character and territorially based;

• the integration of psychiatric patients in the general health care system,

reflected through the involvement of primary care services in their

management and in new forms of hospitalization in general hospitals;

• the creation of an extensive community network of mental health centres;

• adoption by the general public of more positive attitudes towards mental

illness and its treatment, and the adoption of legislative measures aimed at

improving the civil rights of these patients.

All this has meant a new way of understanding mental illness and its management, in

which the emphasis is placed on "normalizing" the care of the patient and the

relationship between patient and society. This concept of "normalization" is essential

since it attempts to overcome the "special status" that previously characterized mental

illness in the Spanish health system.


142 Evidence Based Mental Health Services KCE reports 144

Nevertheless, differences in the implementation of the reform between autonomous

communities are observed. Whereas psychiatric beds in general hospitals as well as

mental health centres in the community are known to be distributed unevenly, the most

important difficulty is the development of intermediate community services and

programs to rehabilitate and resettle patients in the community. Strong tendency to

maintain the old mental hospital is still observed and, if the concept of

deinstitutionalization is accepted by a majority, the inadequate implementation is

criticized (Vazquez-Barquero 2001).

10.3.3 Mental health indicators: heterogeneity between Autonomous

Communities

A limited comparison of the mental health care between ACs and the national and

European levels were made by Salvador-Carulla et. al. in 2006. This exercise, illustrated

by the following table, shows a remarkable heterogeneity between the regions.

Table10.2: Mental Health Care Indicators in Europe, Spain and four

Autonomous Communities: Rate of psychiatric beds per 10,000 inhabitants

and of mental health professionals par 100,000 inhabitants (Source:

Salvador-Carulla et. al. 2006, p. 38 209 )

Europe Spain Catalonia Andalucia Madrid Navarre

Total Psychiatric beds 8.7 4.4 8.3 3.35 2.95 5.13

Psych beds in Psych

hospitals

NA 3.7 6.57 0.04 1.94 0.92

Psych beds in general

hospitals

NA 0.6 0.76 0.75 0.58 0.97

Psychiatrists 9.00 3.6 7.06 5.29 NA 6.71

Psychologists 3.00 1.9 4.90 2.51 NA 4.95

Nurses 27.5 4.2 5.75 6.02 NA 10.08

Social workers 3.35 NA 2.10 1.48 NA 3.42

Psychiatrists in MH

Centers

NA NA 3.57 2.81 3.50 4.19

Psychologists in MH

Centers

NA NA 3.14 2.35 2.18 2.52

Nurses in MH centers NA NA 0.91 1.33 1.66 2.52

Social workers in MH

centers

NA NA 1.08 0.99 1.05 1.62

MH: Mental Health / N. A.: Data not available at the time of completion. Data for Spain and

Europe from WHO Atlas on Mental Health (data for Spain refers to year 1996) (WHO 2005).

Autonomous Communities data refer to year 2002. In Navarre and Catalonia units refer to 1 full

working staff per month. Data from Catalonia are estimates from analysis in 6 small health areas

randomly selected. Data for Catalonia and Madrid have been provided by regional services with

different counting method. Staff in Mental Health Centers does not count staff in centers for child

and adolescent psychiatry in Catalonia and Andalucia209, 213.

10.3.4 Social services for people with disability or dependence

With the reform of the mental health system, an increasing number of services have

been shifted into social care sector 209, 213-215 , but unlike health care, access to social care

is discretionary and a certificate of disability provided by the relevant local authority is

often needed. The formalities can be much more complicated for mental disorders.

According to the process of decentralization, the ACs receive the competencies to

manage social services and the AC social services are responsible for social and

community care for a variety of vulnerable populations including people with intellectual

disabilities, physical disabilities, mental disorders, drug addiction as well as older people.

The services provided by social care departments may include different kinds of facilities

(except hospital residential care and outpatient care). However, some regional services

provide also hospital care for specific groups such as intellectual disabilities or drug

addiction.


KCE Reports 144 Evidence Based Mental Health Services 143

There is no homogeneity of the organization of social interventions between the 17

ACs. Unfortunately, there is a lack of information concerning the social care

expenditure in Spain and in each autonomous region.

Key points

• Deinstitutionalisation and “normalization” have been the main trends of the

Spanish policy since the 1970s, like in other west European countries.

• Psychiatric care has been refocused on primary care and access to

specialized care controlled through a gate-keeper system.

• The referral rate from primary to secondary mental health care was in 1996

about 11%.

• Community mental health centres are the cornerstone of specialized mental

health care.

• Closing of psychiatric hospitals has been often compensated by new

psychiatric beds in general hospitals and by a higher number of psychiatrists.

• However, one of the most important difficulties is the development of

intermediate community services which aim at providing programs to

rehabilitate and resettle patients in the community.

• Organization of mental health care is aiming at a strong integration between

primary care and secondary care. No information was found on the

realisation of these objectives.

• Organization and supply of care can be very different in different regions

(AC’s), and comparison of care supply between regions is quite complex for

purely institutional reasons.

• Given the decentralized nature of the Spanish system, actual level of

psychiatric care also depends on each region’s financial capacity.

• Although the “psychiatric reform” has produced many achievements, a

strong tendency to maintain the old mental hospital is still observed and, if

the concept of deinstitutionalization is accepted by a majority, the

inadequate implementation is criticized.

10.3.5 Mapping of existing services

We use the ‘Service Tree’ uuuuuuu developed by Johnson et al. to map the mental health

services 5 . We refer to chapters 2 and 6 for more information. A synthetic presentation

of the ESMS tree can be found in the synthetic table below.

Table: Synthetic presentation of the ESMS tree

SECURE (1)

RESIDENTIAL Generic acute Hospital (2)

Non-hospital (3)

Non-acute Hospital (4) Time limited (4.1)

Indefinite stay (4.2)

Non-hospital (5) Time limited (5.1)

Indefinite stay (5.2)

DAY & STRUCTURED Acute (6)

ACTIVITY

Non-acute (7) High intensity (7.1)

Low intensity (7.2)

OUT-PATIENT & Emergency care (8) Mobile (8.1)

COMMUNITY

Non-mobile (8.2)

Continuing care (9) Mobile (9.1)

Non-mobile (9.2)

SELF-HELP & NON-PROFESSIONAL (10)

uuuuuuu We use the results of a investigation for Italy and Spain based on the ESMS classification 213


144 Evidence Based Mental Health Services KCE reports 144

10.3.6 The ‘Mental health care tree’ in Spain

A table with an overview of available services in Spain is presented in chapter 14.1.6.

Because the great heterogeneity of the organization in mental health care between the

17 autonomous regions and the lack of information, we will present the mental health

services of regions as an illustration of the existing system in Spain. We will use the

results of a study concerning the provision of services for people with schizophrenia in

five European regions to give a crude presentation of the mental health services

organized in Santander 216, 217 . Santander is the capital of Cantabria (Autonomic

Community in North Spain, population about 560 000, 1.3 % of the total population of

Spain), a university town with a population of about 194 000. This study focuses on

service provision for severely mentally ill persons only.

We use the results of comparison made by Salvador-Carulla et. al. between Italy and

Spain using the European Service Mapping Schedule 213 . In this study, four local

catchment areas are considered: Burlada (Navarra), Barcelona (Catalonia), Loja

(Andalucia) and Madrid. In this study, no distinction was made as to the diagnosis or

severity of involvement of service users. The synthetic table below illustrates the

heterogeneity of the repartition or services in Spain.

To complete the presentation, but without obtain exhaustiveness, we use also a country

report about deinstitutionalisation which concerns the residential services for people

with a disability 214 to describe some services and evaluate their representativeness in

Spain.

The description below mainly deals with “full mental health services” or services

exclusively dealing with persons with mental health disorders. Only in the ESMS

subdivision “residential non-acute non-hospital services” information has been found on

“mixed services” in Spain, meant to support people with different types of disabilities or

social problems.

Table 10.3: Mental health used services in 4 local areas in Spain using the

ESMS – beds occupied per 100 000 inhabitants (Source: Salvador-Carulla,

2005 213

Areas Acute residential Non-acute residential services

services

Hospital Non - Hospital Non-Hospital

Hospital Length of stay Level of support

Time Indefinite 24-Hour Daily Limited

Limited Stay

Burlada 11.2 0 0 0 5.4 0 0

Barcelona 3.6 0 4.4 2.2 0 2.2 0

Loja 2.8 0 0 0 6.4 1.6 0

Madrid 4.3 0 0.7 6.4 3.2 0 0

10.3.6.1 Secure services (1)

One in Santander 216, 217 (out of scope of this report)

10.3.6.2 Residential mental health services

• Generic acute

o Hospital (2)

One in Santander 216 providing 13.3 places/ 100.000 inhabitants. Salvador-Carulla, 2005 213

find between 2.8 and 11.2 acute hospital places/100.000 population in the four analysed

local areas (see Table 10.3). For the whole country, there are 4569 places (about 9.9

places/100.000 population) in “Mental health - Acute Hospital Unit (Unidad de

Hospitalzacion Breve)” (Salvador-Carulla et. al., 2007 214 ). These patients are between 18

and 65 years old and receive 24 hours support and short term care.

o Non-hospital (3)


KCE Reports 144 Evidence Based Mental Health Services 145

Nor Becker nor Salvador-Carulla, 2005 find any residential services providing acute

care outside hospital in the analysed local areas.

• Non-acute

o Hospital (4)

Two services in Santander, indefinite stay 216 ; together they provide 75.1 beds/100.000

population (according to the authors this high number might be caused by the presence

of a university hospital in Santander). Salvador-Carulla et. al. 2005 find in 2 out of 4

areas, Madrid and Barcelona, where large psychiatric hospitals are still open, about 7

beds per 100.000 population 213 ; these 2 areas have a relatively low number of generic

acute hospital beds (see Table 10.3). For the whole country, there are 3 624 places

(7.8/100.000 inhabitants) in “‘Psychiatric Hospitals’ (Hospital Psiquiatrico)”,

providing care to adults (18 to 65 years) and older adults (over 65 years) with mental

disorders.

(Salvador-Carulla et. al., 2007). Another type of services are the ‘Rehabilitation

Hospital units/Therapeutic Communities’ (Unidades Hospitalarias de

rabilitacion/Comunidad Terapeutica). They provide rehabilitation and medium-term

treatment with 24 hour support for adults between 18 and 65 years old. These units

are characterized by few free places and long waiting lists. The number of available

places is function of the capacity (see table below, number for the whole country), the

total amounts to 812 places (about 1.7 per 100.000 population).

Table 10.4: number of available places in Spain in hospital rehabilitation

units (“Therapeutic communities”) in function of the sheltering capacity

Sheltering capacity of hospital units Number of available

places

Between 11 and 30 people 257

Between 31 and 50 people 293

Between 51 and 100 people 60

Between 101 and 200 people 202

Total 812

Source: Salvador-Carulla et. al., 2007 214

o Non-hospital (5)

Two services in Santander, indefinite stay, 24-hour support 216 ; together they provide 3.5

beds/100.000 population. Salvador-Carulla et. al. 2005 describes non-hospital residential

(24 hour services) in 3 out of 4 areas, with 3.2 to 6.4 beds/100.000 population.

Residential non-hospital services providing daily support are described in 2 areas (1.6

resp. 2.2 places/100.000 population).

Generic numbers for Spain are available as well; together about 27.8 places per 100.000

population are available in non-hospital non-acute residential services for persons with

mental disorders; several types exist (Salvador-Carulla et. al., 2007 214 ). First, ‘Sheltered

Accommodations and Supervised Residences for Mental Health (Pisos

Tutelados/Viviendas Supervisadas) for adults between 18 and 65 years old with mental

health problems but who do not need 24 hour support. Inpatients receive short and

long-term care, clinical and care staff overview several days per week and during some

hours per day. 3 to 12 are living in this setting where 1 350 places are available

throughout Spain (about 3 places per 100.000 population). The ‘Mental health

Homes/Residences’ (Residencias Hogar) are conceived to give long term support (24

hours) to people with mental disorders, aged between 18 and 65, and to provide

respite to families. These homes can shelter between 15 and 35 persons, 740 places are

available in the country (1.6 per 100.000 population). Like in France, we find

‘Pensions/Hotels for mental Health’ (Pensiones/hostales para salud Mental) where

the ‘patient’ (adult from 18 to 65 years) has an independent life but can receive some

support if needed (less than 100 places throughout Spain). Medium-stay units for

Mental Health (SM Unidades de Media Estancia) provide 24 hours support for

medium-term care to adults from 18 to 65 years.


146 Evidence Based Mental Health Services KCE reports 144

2 401 places (about 5.2 per 100.000 population) are available in al this kind of centres.

For 24 hours support and long-term care, 8 143 places (about 18 per 100.000

population) are available in ‘Long-stay units for Mental Health’. The staffs of these

centres are shared with ‘medium-stay Units’ and ‘Psychiatric Hospitals’.

Mixed residential services

Only in the ESMS subdivision “residential non-acute non-hospital services” information

has been found on “mixed services” in Spain, meant to support people with different

types of disabilities. We find ‘Centers for People with Pluridisability, Mixed

disabilities, Other disabilities’ (Centro residencial para Personans con

pluridiscapacidad -, Discapacidades Mixtas y Otras Discapacidades). These services are

intended for adults from 18 to 60 years old with more than one disability. The typical

number of places is 25; number of places is available for 3 AC only. They provide 24

hours support, long term care and family respite (the staff is shared with the services

for intellectual disability).

For autonomous adults from 18 to 60 who need some support only some hours per

day, houses or apartments are organized for maximum 7 persons: ‘Alternative

Residential Settings’ (supported living, sheltered homes, …) (Servicios Residenciales

Alternativos). The number of places is available for 3 AC only. Staff is shared with the

other settings of these regions.

10.3.6.3 Day and structured activity

• Acute (6)

Acute day services were identified in three of the four local geographic areas analysed

by Salvador-Carulla et. al. 2005 (3.2 to 4.8 users per 100.000 population per day). This

service type was not identified by Becker et al (2002).

• Non-acute (7)

Becker et al. (2002) could not identify services for day and structured activities in

Santander. Salvador-Carulla et al. 2005 identified “work-related services” in one area

(11.2 users per 100.000 population per day) and “other structured activity” especially in

the 3 other areas (13 to 19.3 users per 100.000 population per month).

10.3.6.4 Out-patient and community mental health services

• Emergency care (8)

o Mobile (8.1)

Nor Becker 216 nor Salvador-Carulla, 2005 213 find any 24-h mobile emergency services in

the areas studied.

o Non-mobile (8.2)

One service community emergency care non-mobile 24 hours in Santander, 42

users/100.000 population per month 216 . This service type (office hours or 24 hours) is

found in all 4 areas in the study of Salvador-Carulla et al. 2005 213 : between 16 and 67.9

users per 100.000 population per month.

• Continuing care (9)

o Mobile (9.1)

Salvador-Carulla et al. (2005) identified this service type in 2 of the 4 areas (1.6 resp.

22.4 users/100.000 population)

o Non-mobile (9.2)

Three services of high intensity in Santander 216 with 2716 users/100.000 population per

month. Salvador-Carulla et al. 2005 213 identified between 609.5 and 1675 users/100.000

population per month in the four areas.


KCE Reports 144 Evidence Based Mental Health Services 147

Like in other analysed countries, psychiatrists provide continuing care for ambulant

patients. The psychiatrist density in Spain is highly heterogeneous, we find only 2.6

psychiatrists for 100 000 inhabitants in Valence, 5.3 in Andalusia and 10.8 in Catalonia 218 .

Globally, we find 3.6 psychiatrists, 1.9 psychologists and 4.2 psychiatric nurses for

100 000 inhabitants in Spain 213 , but because the high heterogeneity, a global figure has

little significance.

10.3.6.5 Self-help and non-professional mental health services

No specific information was found on this subject.

10.4 FINANCING OF THE MENTAL HEALTH CARE SECTOR

10.4.1 Global data

Like for other European countries where the health care system is organized on a

national level, the financing mechanisms of the mental health system are not different

from those of other health care sectors. According to a recent, but very rough

estimation, the mental health care sector would account for 5 % of total health

expenditures. Looking beyond funding from taxation and user charges, the role of

charitable organizations including the church seems to stay important in providing

residential service provision.

10.4.2 Approach per sector of activities

This paragraph aims to describe the financing following the ESMS tree if the data are

available. However, given all the information described above on the Spanish health care

organisation, major problems have arisen in the comparison between Autonomous

Communities- AC (Spanish regions), including on funding issues, mainly for historical

and institutional reasons.

Practical implementation of devolution rules

The way competences and fitting funding have been transferred since 1987 to the AC

did not lead to a clear-cut power sharing between the national level and the regional

entities as the mere level of autonomy depends on each AC (some of them being more

autonomous than others).

More precisely, the rhythm of devolution rules has not been applied in a clear and

uniform timeframe: transfer of political and funding powers was in force in 1981 for

Catalonia, in 1987 for Basque Country, and in 1994 for Canary Islands. Eventually,

devolution process was completed in 2002 only. Transfer of both health care and social

care sectors to the ACs was obviously affected by this political process.

As a result of this specific trait of the Spanish legal system, it is virtually impossible to

establish accurate comparisons on that subject between the different AC but also

between Spain and other countries over the last two decades. The European

Observatory on Health Care Systems described this situation in 2000 as “specially

chaotic in terms of territorial power sharing” 209 .

In most of ACs, the mere availability of data is problematic, and no further analysis can

be conducted. This is particularly true for care provided under the umbrella of social

services. As already mentioned before in this report - see Table XX referring to

Salvador-Carulla 209 - indicators could be defined in Spain for a narrow range of items

only (Psychiatric beds, psychiatrists, psychologists, and nurses) but no reliable

information or data could be found for the following items: social workers, but also

Psychiatrists, Psychologists, Nurses and Social workers working in regional MH Centres.


148 Evidence Based Mental Health Services KCE reports 144

Patient management policy across the ACs

Patient management at each stage of the care pathway, and corresponding funding

policy, greatly varies across ACs. As underlined in many reports (eg Vazquez-Barquero

& Garcia 1999, Salvador-Carulla et al. 2002) closing of psychiatric hospitals has been

applied in very different ways in the different ACs: whereas Andalucia closed all of its

psychiatric hospitals by 2001, Catalonia continued to retain residential subacute and

long term care within psychiatric institutions.

Therefore, the distinction between the different financial streams and financial flows

does not correspond to a clear distinction between the different steps of the patient

pathway.

Political aspects

From a more political point of view, mental health sector has clearly been neglected by

public decision-makers on the regional level and still suffers from low financing. One key

indicator is the low number of psychiatrists working in the public sector: as stated in the

report of WHO of 2005 for Spain, the density of psychiatrists working in the public

sector is approximately half the average in European countries.

Distinction between health care and social care sector

In addition to what has been said above, the implementation of the health reform, some

services initially designed for people with mental disorders or intellectual disabilities

were transferred to the social care sector. However, considering the variable level of

funding for social care across the Spanish ACs, this transfer often led to a reduced

access to services.

Role of the private sector in mental health care supply

Despite the virtually universal coverage of the Spanish population and the legally

guaranteed access to mental health care (mental health care being part of health care

without any restraint), actual implementation of this right is far from being satisfactory

and universal.

Public structures are not always in the position to assume these obligations, as the

mental health sector has been neglected in many ACs. Therefore, a noticeable part of

mental health care is provided by private institutions (especially religious institutions and

charities) for which no reliable data is available.

Main characteristics of the financing system

The main characteristics of the Spanish system can be described as below:

Mental Health Care

The Spanish system is a NHS-style system and thus largely funded by a public taxation

system called “Regimen Commun”. However the latter is not applied to Basque

Country, Navarra, and Canary Islands in which a specific system has been set up

(historical and political reasons).

Social Care

Social care as such is organised and funded by the regional level. However, no reliable

data are available on that point.

Compensation funding

In order to mitigate inequality in access to health care underlined above, a specific

compensation funding system has been set up.


KCE Reports 144 Evidence Based Mental Health Services 149

Table 10.5: Description of the financing of the different mental health (pure

and mixed) institutions and teams

Services or institutions Financing

Full Mental Health Services

Psychiatric beds in Psych. Hospitals Public Taxation System (Except in Basque

Country, Navarra and Canary Islands) &

Compensation funding.

Psychiatric beds in General Hospitals Public Taxation System (Except in Basque

Country, Navarra and Canary Islands)

Psychiatrists Public Taxation System (Except in Basque

Country, Navarra and Canary Islands) &

Compensation funding

Psychologists Public Taxation System (Except in Basque

Count